Reducing infection risk in multiple sclerosis and neuromyelitis optica spectrum disorders: a Brazilian reference center's approach / Redução do risco de infeção em esclerose múltipla e doença do espectro neuromielite óptica: abordagem de um centro de referência brasileiro

Abstract Background Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) are the most common autoimmune diseases of the central nervous system (CNS). They present chronic relapsing courses that demand treatment with disease-modifying drugs (DMDs) to prevent inflammatory activity. Disease-modifying drugs lead to immunomodulation or immunosuppression through diverse mechanisms (e.g., shifting lymphocyte and cytokine profile, suppressing specific lymphocyte subpopulations). Thus, patients are more prone to infectious complications and associated worsening of disease. Objective To present feasible strategies for mitigating the infection risk of MS and NMOSD treated patients. Methods Targeted literature review concerning the management of infection risk with an emphasis on vaccination, therapy-specific measures, and particularities of the Brazilian endemic infectious diseases' scenario. Conclusion We propose a vaccination schedule, infectious screening routine, and prophylactic measures based on the current scientific evidence. Awareness of emergent tropical diseases is necessary due to evidence of demyelinating events and possible parainfectious cases of MS and NMOSD.

Resumo Antecedentes A esclerose múltipla (EM) e a doença do espectro neuromielite optica (NMOSD) são as doenças autoimunes mais comuns do sistema nervoso central (SNC). Ambas apresentam curso crônico com recaídas (surtos) e exigem tratamento com drogas modificadoras de doenças (DMDs) para a prevenção de atividade inflamatória. As DMDs levam à imunomodulação ou imunossupressão através de diversos mecanismos (por exemplo deslocando e/ou suprimindo subpopulações linfocitárias ou alterando perfil de produção de citocinas). Desta forma, os pacientes com EM ou NMOSD são mais propensos a complicações infecciosas, as quais podem levar ao agravamento de suas doenças de base. Objetivo Apresentar estratégias viáveis para mitigar o risco de infecção de pacientes com EM ou NMOSD sob tratamento. Métodos Revisão bibliográfica focada em manejo de risco de infecção com ênfase em vacinação, medidas específicas de tratamento e particularidades de doenças infecciosas endêmicas do Brasil. Conclusão Propomos um calendário de vacinação, rotina de triagem infecciosa e medidas profiláticas baseadas em evidências científicas atuais. A conscientização das doenças tropicais emergentes é necessária devido a evidências de eventos desmielinizantes e possíveis casos parainfecciosos de EM e NMOSD.

Human Papillomavirus (HPV) seroprevalence, cervical HPV prevalence, genotype distribution and cytological lesions in solid organ transplant recipients and immunocompetent women in Sao Paulo, Brazil.

INTRODUCTION: Solid organ transplant (SOT) recipients are at increased risk of Human Papillomavirus (HPV) persistent infection and disease. This study aimed to evaluate HPV seroprevalence, cervical HPV prevalence, genotype distribution, and frequency of HPV-related cervical lesions in SOT recipients in comparison to immunocompetent women. METHODS: Cross-sectional study including SOT and immunocompetent women aged 18 to 45 years who denied previous HPV-related lesions. Cervical samples were screened for HPV-DNA by a polymerase chain reaction (PCR)-based DNA microarray system (PapilloCheck®) and squamous intraepithelial lesions (SIL) by liquid-based cytology. A multiplexed pseudovirion-based serology assay (PsV-Luminex) was used to measure HPV serum antibodies. RESULTS: 125 SOT and 132 immunocompetent women were enrolled. Cervical samples were collected from 113 SOT and 127 immunocompetent women who had initiated sexual activity. HPV-DNA prevalence was higher in SOT than in immunocompetent women (29.6% vs. 20.2%, p = 0.112), but this difference was not statistically significant. High-risk (HR)-HPV was significantly more frequent in SOT than in immunocompetent women (19.4% vs. 7.9%, p = 0.014). Simultaneous infection with ≥2 HR-HPV types was found in 3.1% of SOT and 0.9% of immunocompetent women. HPV seropositivity for at least one HPV type was high in both groups: 63.8% of 105 SOT and 69.7% of 119 immunocompetent women (p = 0.524). Low-grade (LSIL) and high-grade SIL (HSIL) were significantly more frequent in SOT (9.7% and 5.3%, respectively) than in immunocompetent women (1.6% and 0.8%, respectively) (p = 0.001). CONCLUSIONS: These results may reflect the increased risk of HPV persistent infection and disease progression in SOT women due to chronic immunosuppression.

Adverse events following immunization of elderly with COVID-19 inactivated virus vaccine (CoronaVac) in Southeastern Brazil: an active surveillance study

ABSTRACT Healthcare workers, the elderly and other vulnerable populations were the first to receive COVID-19 vaccines in public health programs. There were few vaccine safety data available on the elderly. This observational study aimed to evaluate the inactivated vaccine (CoronaVac) safety in the elderly, at the beginning of the vaccination program, in Sao Paulo city, Brazil. The elderly people that received CoronaVac at the Reference Center for Special Immunobiologicals (CRIE) or at home, administered by the Interdisciplinary Home Care Team (NADI) of the Hospital das Clinicas were invited to participate in this phase 4 observational study. The vaccination schedule included two CoronaVac doses 28 days apart. The information on solicited and unsolicited adverse events following immunization were collected by phone calls on days 4 and 8 after each vaccine dose. We enrolled 158 adults aged 65 to 101 years (mean of 84.1 years); 63.9% were females and 95.6% had chronic conditions, 21.5% had moderate or severe impairment in daily living activities; 34.2% were pre-frail and 19.6% were frail. We were able to contact 95.6% and 91.6% of the vaccinated people, after the first and second doses, respectively; 31.8% and 23.4% of the contacted participants reported some adverse events (AE) following the first and second doses, respectively. Pain at the injection site, fatigue, myalgia and headaches were the most frequent solicited AE. Most AE were mild to moderate. There were eight severe adverse events, but none of them were considered related to the vaccine. The CoronaVac was safe and well tolerated by these adults of advanced age with frailty and comorbidities.

Low tetanus-diphtheria-acellular pertussis (Tdap) vaccine coverage among healthcare workers in a quaternary university hospital in São Paulo, Brazil: need for continuous surveillance and implementation of active strategies

Abstract Introduction: Vaccination with tetanus-diphtheria-acellular pertussis (Tdap) has been recommended for healthcare workers (HCWs) by Brazilian Ministry of Health since November 2014. Objective: To describe the strategies implemented to improve Tdap uptake, cumulative vaccine coverage after each intervention, variables associated to Tdap vaccination, and reasons for non-vaccination among HCWs of the main building of a quaternary hospital attached to the Sao Paulo University Medical School. Methods: A list of HCWs eligible for pertussis vaccination was generated. From April to December 2015, the following interventions were implemented: note on intern journal reminding the importance of pertussis vaccination; email to the head nurses strengthening vaccine recommendations; lectures on pertussis and Tdap for physicians of Obstetrics and Neonatology Clinics; on-site vaccination by mobile teams at the Obstetrics, Neonatology, and Anesthesiology Clinics. Vaccine coverage was accessed at the end of each month. Multivariate Poisson regression model with a robust error variance was used to evaluate variables associated with Tdap vaccination. Reasons for non-vaccination were evaluated from January to May 2017 through phone calls for HCWs who had not received Tdap. Results: The study included 456 HCWs. After the interventions, Tdap coverage raised from 2.8% to 41.2%. In the multivariate analysis, occupation (physician), working place (obstetrics or anesthesiology) and influenza vaccination in 2015 were independently associated to Tdap vaccination. The main reason for non-vaccination was unawareness of Tdap recommendations. Conclusions: Tdap uptake among HCWs was low in our hospital. Providing vaccination at convenient places/times for HCW seems to be the most efficient strategy to increase vaccine uptake.

Healthcare resource utilization and costs of outpatient follow-up after liver transplantation in a university hospital in São Paulo, Brazil: cost description study / Utilização de recursos em saúde e custos do acompanhamento ambulatorial pós-transplante de fígado em um hospital universitário em São Paulo, Brasil: estudo de descrição de custos

CONTEXT AND OBJECTIVE: Data on the costs of outpatient follow-up after liver transplantation are scarce in Brazil. The purpose of the present study was to estimate the direct medical costs of the outpatient follow-up after liver transplantation, from the first outpatient visit after transplantation to five years after transplantation. DESIGN AND SETTING: Cost description study conducted in a university hospital in São Paulo, Brazil. METHODS: Cost data were available for 20 adults who underwent liver transplantation due to acute liver failure (ALF) from 2005 to 2009. The data were retrospectively retrieved from medical records and the hospital accounting information system from December 2010 to January 2011. RESULTS: Mean cost per patient/year was R$ 13,569 (US$ 5,824). The first year of follow-up was the most expensive (R$ 32,546 or US$ 13,968), and medication was the main driver of total costs, accounting for 85% of the total costs over the five-year period and 71.9% of the first-year total costs. In the second year after transplantation, the mean total costs were about half of the amount of the first-year costs (R$ 15,165 or US$ 6,509). Medication was the largest contributor to the costs followed by hospitalization, over the five-year period. In the fourth year, the costs of diagnostic tests exceeded the hospitalization costs. CONCLUSION: This analysis provides significant insight into the costs of outpatient follow-up after liver transplantation due to ALF and the participation of each cost component in the Brazilian setting. .

CONTEXTO E OBJETIVO: Dados sobre os custos do seguimento ambulatorial pós-transplante de fígado são escassos no Brasil. O objetivo do presente estudo foi estimar os custos diretos médicos do seguimento ambulatorial pós-transplante de fígado a partir da primeira visita ambulatorial pós-transplante até cinco anos após o transplante. TIPO DE ESTUDO E LOCAL: Estudo de descrição de custos realizado em um hospital universitário em São Paulo, Brasil. MÉTODOS: Dados de custos estavam disponíveis para 20 adultos que foram submetidos a transplante de fígado devido a insuficiência hepática aguda (IHA) de 2005 a 2009. Os dados foram retrospectivamente obtidos em prontuários médicos e no sistema de informação contábil hospitalar de dezembro de 2010 a janeiro de 2011. RESULTADOS: A média de custo por paciente/ano foi de R$ 13.569 (US$ 5.824). O primeiro ano de acompanhamento foi o mais caro, R$ 32.546 (US$ 13,968), e medicação foi o principal impulsionador dos custos totais, respondendo por 85% dos custos totais no período de cinco anos e 71,9% dos custos totais do primeiro ano. No segundo ano pós-transplante, os custos médios totais foram cerca da metade do montante de custos do primeiro ano (R$ 15.165 ou US$ 6,509). Medicação foi o maior contribuinte para os custos seguido da internação, no período de cinco anos. No quarto ano, os custos dos testes diagnósticos superam os custos de internação. CONCLUSÃO: Esta análise proporciona uma compreensão significativa dos custos do seguimento ambulatorial pós-transplante de fígado por IHA e a participação de cada componente de custo no cenário brasileiro. .

Spontaneous reporting of adverse events following pandemic influenza A (H1N1) immunization in a reference center in the State of Sao Paulo, Brazil

Introduction This paper describes adverse events (AEs) temporally associated to the pandemic influenza A (H1N1) vaccine observed in a reference center in São Paulo, Brazil, during a 2010 mass vaccination campaign. Methods A retrospective study involving persons who sought medical care for AEs following influenza vaccination. Data were retrieved from medical records, vaccine AE notification forms, and a computerized system for immunobiological registration. Results Sixty-six vaccinees sought medical care for AEs after immunization. The most frequent AEs were fever, headache, myalgia, and pain at the injection site. No serious AEs were reported. Conclusions Few vaccinees spontaneously reported AEs to influenza A (H1N1) vaccine at this center. .