Street Cleaning Trucks as Potential Sources of Legionella pneumophila.

In 2015, Legionnaires' disease was diagnosed in a street cleaning worker. We found Legionella pneumophila serogroup 1 in the water and internal foam from the tanks of 2 trucks used by the worker during the incubation period. The internal foam was removed, and a Legionella prevention program was implemented.

Can we rely on the antiretroviral treatment as the only means for human immunodeficiency virusprevention? A Public Health perspective.

The evidence that supports the preventive effect of combination antiretroviral treatment (cART) in HIV sexual transmission suggested the so-called 'treatment as prevention' (TAP) strategy as a promising tool for slowing down HIV transmission. As the messages and attitudes towards condom use in the context of TAP appear to be somehow confusing, the aim here is to assess whether relying on cART alone to prevent HIV transmission can currently be recommended from the Public Health perspective. A review is made of the literature on the effects of TAP strategy on HIV transmission and the epidemiology of other sexual transmitted infections (STIs) in the cART era, and recommendations from Public Health institutions on the TAP as of February 2014. The evolution of HIV and other STIs in Barcelona from 2007 to 2012 has also been analysed. Given that the widespread use of cART has coincided with an increasing incidence of HIV and other STIs, mainly amongst men who have sex with men, a combination and diversified prevention methods should always be considered and recommended in counselling. An informed decision on whether to stop using condoms should only be made by partners within stable couples, and after receiving all the up-to-date information regarding TAP. From the public health perspective, primary prevention should be a priority; therefore relying on cART alone is not a sufficient strategy to prevent new HIV and other STIs.

Evidence for positive selection of hepatitis A virus antigenic variants in vaccinated men-having-sex-with men patients: Implications for immunization policies.

BACKGROUND: A huge outbreak in the men-having-sex-with-men (MSM) has hit Europe during the years 2016-2018. Outbreak control has been hampered by vaccine shortages in many countries, and to minimize their impact, reduction of antigen doses has been implemented. However, these measures may have consequences on the evolution of hepatitis A virus (HAV), leading to the emergence of antigenic variants. Cases in vaccinated MSM patients have been detected in Barcelona, opening the possibility to study HAV evolution under immune pressure. METHODS: We performed deep-sequencing analysis of ten overlapping fragments covering the complete capsid coding region of HAV. A total of 14578255 reads were obtained and used for the analysis of virus evolution in vaccinated versus non-vaccinated patients. We estimated maximum and minimum mutation frequencies, and Shannon entropy in the quasispecies of each patient. Non-synonymous (NSyn) mutations affecting residues exposed in the capsid surface were located, with respect to epitopes, using the recently described crystal structure of HAV, as an indication of its potential role in escaping to the effect of vaccines. FINDINGS: HAV evolution at the quasispecies level, in non-vaccinated and vaccinated patients, revealed higher diversity in epitope-coding regions of the vaccinated group. Although amino acid replacements occurring in and around the epitopes were observed in both groups, their abundance was significantly higher in the quasispecies of vaccinated patients, indicating ongoing processes of fixation. INTERPRETATION: Our data suggest positive selection of antigenic variants in some vaccinated patients, raising concerns for new vaccination polices directed to the MSM group.

The decline of the incidence of meningococcal disease in Barcelona between 1988 and 2015: the influence of the vaccine against serogroup C. / El declive de la incidencia de enfermedad meningocócica en Barcelona entre 1988 y 2015: la influencia de la vacunación frente al serogrupo C.

INTRODUCTION AND OBJECTIVE: The purpose of this study was to describe the evolution of meningococcal disease (MD) in the city of Barcelona between 1988 and 2015 and to assess the impact of the vaccine against serogroup C. MATERIALS AND METHODOLOGY: The evolution of MD and by serogroup was analysed using the information included in the mandatory notification diseases registry. Incidences of all serogroups between the periods of before and after the implementation of the serogroup C vaccine in 2000 were compared. Vaccination coverage among cases, serogroup among vaccinated cases and mortality and case fatality rates were analysed. RESULTS: MD has evolved from an incidence rate in children aged under 1 of 63.09 cases per 100,000 in 1997-2000 to 15.44 per 100,000 in 2001-2015. All MD serogroups incidences decreased after the implementation of the vaccine, especially for serogroup C among children aged between 1 and 4. Since 2000 vaccine coverage in MD cases by this serogroup was 7.6% while in those affected by serogroup B it was 35.0% (p<.01). Among those vaccinated, 66.4% of cases were serogroup B and 5.2% were C (p<.01). Mortality and case fatality rates were 7.7% and 0.19/100,000 respectively, without significant changes in time regarding case fatality. CONCLUSIONS: Incidence caused by serogroups B and C has decreased after the systematic vaccination against serogroup C. Vaccination against serogroup B could further reduce the impact of this lethal disease which has not decreased during this period.

Effectiveness of hepatitis A vaccination as post-exposure prophylaxis.

Hepatitis A (HA) has been a vaccine-preventable disease since 1995. In Catalonia, a universal combined hepatitis A+B vaccination program of preadolescents was initiated at the end of 1998. However, outbreaks are reported each year and post-exposure prophylaxis (PEP) with hepatitis A virus (HAV) vaccine or immunoglobulin (IG) is recommended to avoid cases. The aim of this study was to assess the effectiveness of HAV vaccine and IG in preventing hepatitis A cases in susceptible exposed people. A retrospective cohort study of contacts of HA cases involved in outbreaks reported in Catalonia between January 2006 and December 2012 was made. The rate ratios and 95% confidence intervals (CI) of HA in susceptible contacts receiving HAV or IG versus those without PEP were calculated. There were 3550 exposed persons in the outbreaks studied: 2381 received one dose of HAV vaccine (Hepatitis A or hepatitis A+B), 190 received IG, and 611 received no PEP. 368 exposed subjects received one dose of HAV vaccine and IG simultaneously and were excluded from the study. The effectiveness of PEP was 97.6% (95% CI 96.2-98.6) for HAV vaccine and 98.3% (95% CI 91.3-99.9) for IG; the differences were not statistically significant (p = 0.36). The elevated effectiveness of HAV vaccination for PEP in HA outbreaks, similar to that of IG, and the long-term protection of active immunization, supports the preferential use of vaccination to avoid secondary cases.

Evolution of acute hepatitis C virus infection in a large European city: Trends and new patterns.

The aims of this study were to describe the evolution of acute hepatitis C virus (HCV) infections since 2004 and to determine its associated factors. Acute HCV infections diagnosed in Barcelona from 2004 to 2015 were included. Incidence ratios (IR) were then estimated for sex and age groups. Cases were grouped between 2004-2005, 2006-2011 and 2012-2015, and their incidence rate ratios (IRR) were calculated. In addition, risk factors for acute HCV infection were identified using multinomial logistic regression for complete, available and multiple imputed data. 204 new HCV cases were identified. Two peaks of higher IR of acute HCV infection in 2005 and 2013 were observed. Men and those aged 35-54 had higher IR. IRR for men was 2.9 times greater than in women (95% confidence intervals (CI): 1.8 ‒ 4.7). Factors related to the period 2012-2015 (versus 2006-2011) were: a) sexual risk factor for transmission versus nosocomial (relative-risk ratio (RRR): 13.0; 95% CI: 2.3 ‒ 72.1), b) higher educated versus lower (RRR: 5.4; 95% CI: 1.6 ‒ 18.7), and c) HIV co-infected versus not HIV-infected (RRR: 53.1; 95% CI: 5.7 ‒ 492.6). This is one of the few studies showing IR and RRRs of acute HCV infections and the first focused on a large city in Spain. Sexual risk for transmission between men, higher educational level and HIV co-infection are important factors for understanding current HCV epidemic. There has been a partial shift in the pattern of the risk factor for transmission from nosocomial to sexual.

[Norovirus outbreaks in geriatric centers: importance of an early detection]. / Brotes de infección por norovirus en centros geriátricos: importancia de una detección precoz.

BACKGROUND AND OBJECTIVES: Acute gastroenteritis (AGE) outbreaks of norovirus (NV) occur frequently in nursing homes. Gastrointestinal disorders and degree of dependence of residents complicate early detection and implementation of control measures. Our study's aim was to determine the incidence of NV in elderly care centers, transmission mechanisms and circulating genotypes. PATIENTS AND METHODS: An epidemiological study of NV outbreaks reported to the Public Health Agency of Barcelona 2010-2012 was performed. The attack rate, outbreak duration, symptomatology and identified NV genotypes were analyzed. RESULTS: In total, 27 NV outbreaks were reported and 5 (18.5%) occurred in nursing homes (95 cases with lethality of 1.05%). The etiology of one of the five outbreaks could not be confirmed because of late notification. Four of the outbreaks were attributed to person-to-person transmission. The outbreak duration and attack rate among resident person-to-person transmission were significantly higher compared to common exposure transmission. Genotype GII.4 was predominant. CONCLUSIONS: The identification of critical points and the use of clinical alarm systems could prevent and minimize the spreading and severity of these outbreaks.

Changes in the epidemiology of hepatitis A outbreaks 13 years after the introduction of a mass vaccination program.

A hepatitis A+B vaccine vaccination program of 12-year-olds was introduced in Catalonia in 1998. The aim of this study was to investigate the evolution of hepatitis A outbreaks in Catalonia and estimate the preventable fraction of cases associated with outbreaks as a measure of the impact of the vaccination program. Hepatitis A outbreaks reported to the Health Department between 1991 and 2012 were analyzed. The incidence rates of outbreaks, outbreak-associated cases and hospitalizations were calculated. The preventable fraction (PF) and 95% confidence intervals (CI) were estimated for the whole study period (pre-vaccination and post-vaccination) and the post-vaccination period.   One-hundred-eight (108) outbreaks (rate of 2.21 per 10(6) persons-year) were reported in the pre-vaccination period and 258 outbreaks (rate of 2.82 per 10(6) persons-year) in the post-vaccination period. The rate of cases associated with outbreaks was 1.52 per 10(5) persons-year in the pre-vaccination period and 1.28 per 10(5) persons-year in the post-vaccination period. Hospitalization rates were 0.08 and 0.75 per 10(6) persons-year, respectively. The number of person-to-person outbreaks whose index case was a school contact decreased in the post-vaccination period (aOR 2.72; 95%CI 1.35-5.48), but outbreaks whose index case was a man who has sex with men (MSM) or an immigrant increased. The PF of all outbreak-associated cases was 6.46% (95%CI 3.11-9.82) and the highest PF was in the 15-24 years age group (42.53%; 95%CI 29.30-55.75). In the 0-4 years age group, the PF was 18.35% (95%CI 9.59-27.11), suggesting a protective herd effect in unvaccinated subjects. Vaccination of immigrants traveling to endemic countries and MSM should be reinforced.

Evaluation of reported cases of pertussis: epidemiological study in a large city in Spain.

We retrospectively analysed the incidence rate of reported cases of pertussis in Barcelona during 2009-2012 according to age, sex, type of medical centre and vaccination status. We included 748 confirmed or suspected cases, 613 (82.0 %) of which were confirmed by laboratory testing and the remaining 135 (18.0 %) by epidemiological evidence. The highest reported incidence of pertussis was amongst <1 year olds [96.1 per 100,000 person-years, 95 % confidence interval (CI): 84.3-109.1]. The majority of confirmed and suspected cases were reported in 2011 and 2012, and the total incidence (confirmed or suspected) was 6.3 (95 % CI: 5.6-6.9) and 4.2 (95 % CI: 3.6-4.7) per 100,000 person-years, respectively. Incidence increased significantly (P = 0.001) in 2011-2012 compared with 2009. Most confirmed cases occurred in children <1 year old (87.9 %). Cases were confirmed by real-time (RT)-PCR (87.5 %; 95 % CI: 81.3-87.6) and bacterial culture (13.7 %; 95 % CI: 11.0-17.1). We recommend performing RT-PCR in suspected cases with no epidemiological link to a confirmed case.

Group A ß-hemolytic streptococcal pharyngotonsillitis outbreak.

The aim was to describe an outbreak of group A ß-hemolytic streptococcal pharyngotonsillitis in health care professionals. This is a cross-sectional descriptive study of 17 clients who dined at the same table in a restaurant in Barcelona in July 2012. The frequency, timing and severity of symptoms were analyzed, as were demographic variables and others concerning the food ingested. The attack rate was 58.8%. Six of the 10 clients were positive for group A ß-hemolytic streptococcal. Six of the 13 individuals who handled the food involved in the dinner had symptoms. No association was identified with the food consumed. There is epidemiological evidence of foodborne group A ß-hemolytic streptococcal transmission, but respiratory transmission could not be ruled out.

Person-to-person transmission of norovirus resulting in an outbreak of acute gastroenteritis at a summer camp.

BACKGROUND: A significant proportion of norovirus (NV) gastroenteritis outbreaks described in the Spanish literature have been because of contaminated food or water. AIM: This study describes an outbreak of acute gastroenteritis because of NV in which there was person-to-person transmission. MATERIALS AND METHODS: A retrospective cohort study was carried out; we established the case definition for primary and secondary cases. An epidemiological survey was designed, including possible food exposures, and clinical and laboratory data. Water and stool samples were taken from affected individuals and food handlers. The presence of NV was detected using a reverse transcription-PCR assay. We analyzed the risk of gastroenteritis using relative risk and its 95% confidence interval as the measure of association, and estimated the basic reproductive number (R0). RESULTS: The primary attack rate was 45.0%, with no significant differences between sexes. The secondary attack rate during the camp stay was 22.7%. The basic reproductive number for 5 days was R0=2.62. The most frequent symptoms were abdominal pain (85.7%) and vomiting (81.9%). Epidemiological analysis showed no association with food or drinking water. A total of 66.6% (8/12) of stool samples tested positive for NV (genogroup II). CONCLUSION: Control measures in general, and hand hygiene in particular, should be extended to the families once the children return home, to prevent secondary cases in NV outbreaks.

[Impact of the 28/2005 Spanish smoking law on second-hand smoke exposure in Barcelona]. / Impacto de la Ley 28/2005 de medidas sanitarias frente al tabaquismo en la prevalencia de la exposición al humo ambiental del tabaco en Barcelona.

OBJECTIVE: To assess the impact of the 28/2005 Spanish smoking law on exposure to second-hand smoke (SHS) in Barcelona. METHODS: We performed a pre-post evaluation study. Two cross-sectional surveys were compared. Data were obtained from the Barcelona Health Surveys of 2000 and 2006. The prevalence of SHS exposure among non-smoking adults was analyzed by setting (home, workplace and leisure time) and sociodemographic variables. RESULTS: SHS exposure in non-smokers significantly decreased between 2000 and 2006 (p < 0.01). Odds ratios adjusted by sex, age and social class were 0.7 (95% CI: 0.6-0.8) for home and 0.2 (95% CI: 0.2-0.3) for workplace exposure in 2006 compared with 2000. In both settings, the decrease in exposure was greater in the higher social classes. After the implementation of the law, almost 50% of the population remained exposed to SHS during leisure time, younger people being the most exposed (83.5%). CONCLUSION: After the implementation of the law, the prevalence of SHS exposure in non-smokers in Barcelona decreased significantly in workplaces and in the home. Nevertheless, nearly half of the population remained exposed to SHS during leisure time.