[Implementation of a network drug strategy: the case of praziquantel]. / Implementación de una estrategia de medicamentos en red: el caso de praziquantel.

Parasitic infections cause a huge burden of disease and are a current public health problem. The category of emerging or re-emerging disease is influenced by phenomena that occur in today's interconnected world because of globalization, the displacement of people, trade, uncoordinated urbanization and climate change, they have a very important influence on transmission of these diseases. In 2021 there was an increase in the number of patients who have required treatment for diphyllobothriasis in the Los Ríos Region. This article reviews aspects related to integrated Health Service networks to provide access to pharmacological treatments to patients diagnosed with diphyllobothriasis (tapeworm infection), implemented by the Valdivia Health Service Department, in collaboration with the San José de Osorno hospital, primary care centers and private centers in the Los Ríos Region.

Implementación de una estrategia de medicamentos en red: el caso de praziquantel / Implementation of a network drug strategy: the case of praziquantel

Resumen Las infecciones parasitarias provocan una enorme carga de enfermedad y constituyen un problema presente para la salud pública. Las enfermedades emergentes o reemergentes se ven influenciadas por fenómenos del mundo actual interconectado producto de la globalización, el desplazamiento de las personas, el comercio, la urbanización descoordinada y el cambio climático, contribuyendo en la transmisión de estas enfermedades. En el año 2021 hubo un aumento de la cantidad de pacientes que han requerido tratamiento para la difilobotriasis en la Región de los Ríos. Se revisan los aspectos relacionados con las redes integradas de servicios de salud para el acceso al tratamiento farmacológico a pacientes con diagnóstico de difilobotriasis, implementado por la Dirección de Servicio de Salud Valdivia, en colaboración con el hospital San José de Osorno, centros de atención primaria y centros privados de la Región de los Ríos.

Abstract Parasitic infections cause a huge burden of disease and are a current public health problem. The category of emerging or re-emerging disease is influenced by phenomena that occur in today's interconnected world because of globalization, the displacement of people, trade, uncoordinated urbanization and climate change, they have a very important influence on transmission of these diseases. In 2021 there was an increase in the number of patients who have required treatment for diphyllobothriasis in the Los Ríos Region. This article reviews aspects related to integrated Health Service networks to provide access to pharmacological treatments to patients diagnosed with diphyllobothriasis (tapeworm infection), implemented by the Valdivia Health Service Department, in collaboration with the San José de Osorno hospital, primary care centers and private centers in the Los Ríos Region.

'Candidatus Neoehrlichia mikurensis' in Europe.

'Candidatus Neoehrlichia mikurensis' is an uncultured emerging bacterium that is provisionally included in the family Anaplasmataceae. In Europe, it is transmitted by Ixodes ricinus ticks. Rodents are the reservoirs. It is widely distributed in mammals (both wild and domestic) and birds. It causes an inflammatory disease in humans with underlying diseases, but the microorganism also affects immunocompetent individuals in which asymptomatic infection has been recognized. A high degree of suspicion and the use of molecular tools are needed for the correct diagnosis. Efforts to cultivate it and to investigate its pathogenesis should be a priority.

Isolation of Rickettsia amblyommatis in HUVEC line.

Rickettsia amblyommatis, formerly named Rickettsia amblyommii and 'Candidatus Rickettsia amblyommii' is an intracellular bacterium belonging to the spotted fever group Rickettsia. It is highly prevalent in Amblyomma americanum and in other Amblyomma spp. throughout the Western Hemisphere. R. amblyommatis has been cultivated in chicken fibroblast, primary embryonated chicken eggs, Vero cells and arthropod-derived cells. Because of the affinity of rickettsiae to invade vascular endothelial cells, we tried to isolate R. amblyommatis from a nymph of Amblyomma cajennense s.l. collected in Saltillo (Coahulia, Mexico) using human umbilical vein endothelial cells (HUVEC). One tick half was analysed by ompA PCR and was found to be positive for R. amblyommatis. The other half was selected for in vitro culture of Rickettsia spp. It was triturated in 1 mL of endothelial cell growth medium with 1% antibiotic-antimycotic solution, and the homogenate was inoculated into a HUVEC line. Culture was maintained at 33°C in endothelial cell growth medium plus 2 mM l-glutamine and 2% fetal calf serum, with 5% CO2. The medium was changed weekly. Culture was checked by Gimenez stain for Rickettsia-like intracellular organisms. After 48 days of incubation, Rickettsia-like organisms were observed in HUVEC. PCR assays and sequencing of ompA gene in the culture suspension showed 100% identity with R. amblyommatis. This isolate was successfully established in HUVEC, and it has been deposited in the collection of the Center of Rickettsioses and Arthropod-Borne Diseases, Infectious Diseases Department, Hospital San Pedro-Center of Biomedical Research from La Rioja, Logroño, Spain. The HUVEC line is a useful tool for the isolation of R. amblyommatis.

Molecular surveillance of measles and rubella in the WHO European Region: new challenges in the elimination phase.

BACKGROUND: The WHO European Region (EUR) has adopted the goal of eliminating measles and rubella but individual countries perform differently in achieving this goal. Measles virus spread across the EUR by mobile groups has recently led to large outbreaks in the insufficiently vaccinated resident population. As an instrument for monitoring the elimination process and verifying the interruption of endemic virus transmission, molecular surveillance has to provide valid and representative data. Irrespective of the country's specific situation, it is required to ensure the functionality of the laboratory surveillance that is supported by the WHO Global Measles and Rubella Laboratory Network. AIMS: To investigate whether the molecular surveillance in the EUR is adequate for the challenges in the elimination phase, we addressed the quality assurance of molecular data, the continuity and intensity of molecular monitoring, and the analysis of transmission chains. SOURCES: Published articles, the molecular External Quality Assessment Programme of the WHO, the Centralized Information System for Infectious Diseases of the WHO EUR and the WHO Measles and Rubella Nucleotide Surveillance databases served as information sources. CONTENT: Molecular proficiency testing conducted by the WHO in 2016 has shown that the expertise for measles and rubella virus genotyping exists in all parts of the EUR. The analysis of surveillance data reported nationally to the WHO in 2013-2016 has revealed some countries with outbreaks but not sufficiently representative molecular data. Long-lasting supranational MV transmission chains were identified. IMPLICATIONS: A more systematic molecular monitoring and recording of the transmission pattern for the whole EUR could help to create a meaningful picture of the elimination process.

Challenges of measles and rubella laboratory diagnostic in the era of elimination.

The Member States of the WHO European Region adopted the goal of measles and rubella elimination more than 10 years ago, but so far only 21 of 53 countries have reached this target. Laboratory investigation of suspected cases is essential to support disease elimination efforts. Therefore, WHO maintains a network of accredited laboratories providing high-quality testing. Laboratory investigation heavily relies on specific IgM serology and increasingly on virus detection by reverse transcription (RT)-PCR, but other methods such as IgG avidity testing and genetic characterization of virus strains have gained in importance. In elimination settings, often few samples from suspected cases are available for testing, but testing proficiency must be maintained. The predictive value of an IgM-positive result decreases and other rash-fever disease aetiologies become more important. In addition, cases with a rash after measles/rubella vaccination or with mild disease after waning of vaccine-induced antibodies are seen more often. Thus, it is necessary to perform comprehensive and potentially time-consuming and costly investigations of every suspected case using quality-controlled laboratory methods. At the same time rapid feedback to public health officers is required for timely interventions. The introduction of new laboratory methods for comprehensive case investigations requires training of staff under the supervision of WHO-accredited reference laboratories and the definition of appropriate test algorithms. Clinical, laboratory, and epidemiological data are essential for final case classification and investigation of chains of transmission in the endgame of measles and rubella elimination.

Cigarrillos eléctrónicos: ¿Podemos recomendar su uso? / Electronic cigarettes: can we recommend its use?

Los cigarrillos electrónicos (Cig-e) son dispositivos que contienen un líquido compuesto por un solvente, saborizantes y, en la mayoría de los casos, nicotina. Este liquido, al ser calentado en el dispositivo, se vaporiza, siendo aspirado por el usuario. En los últimos años, el uso de los Cig-e ha aumentado rápidamente, especialmente entre escolares y gente joven, sin existir hasta el día de hoy evidencias ciertas sobre su seguridad y efectos a largo plazo. En este artículo revisamos la evidencia existente en cuanto a los efectos y seguridad de cada uno de los componentes de los Cig-e y analizamos sus potenciales indicaciones en distintos escenarios clínicos.

Electronic cigarettes (Cig-e) are devices that contain a liquid composed of a solvent, flavors and, in most cases, nicotine. This liquid, when heated in the device, vaporizes, being aspirated by the user. In recent years, the use of Cig-e has increased rapidly, especially among schoolchildren and young people, with no clear evidence of safety and long-term effects to date. In this article we review the existing evidence regarding the effects and safety of each of the components of Cig-e and analyze their potential indications in different clinical scenarios.

Detection of tick-borne Anaplasma bovis, Anaplasma phagocytophilum and Anaplasma centrale in Spain.

The genus Anaplasma (Rickettsiales: Anaplasmataceae) includes species of medical and veterinary importance. The presence of Anaplasma spp. in ticks from birds, as well as in Haemaphysalis punctata (Ixodida: Ixodidae) specimens collected from cattle and vegetation in northern Spain was investigated. A total of 336 ticks from birds [174 Ixodes frontalis (Ixodida: Ixodidae), 108 H. punctata, 34 Hyalomma marginatum (Ixodida: Ixodidae), 17 Ixodes ricinus (Ixodida: Ixodidae) and three Ixodes spp.], and 181 H. punctata specimens collected from cattle (n = 71) and vegetation (n = 110) were analysed. Anaplasma bovis was detected in five H. punctata, including two from birds (1.9%) and three from vegetation (2.7%). Four I. frontalis (2.3%) (one co-infected with 'Candidatus Midichloria mitochondrii') and one I. ricinus (5.9%) removed from birds, as well as four H. punctata (5.6%) collected from cattle showed Anaplasma phagocytophilum infection. In addition, Anaplasma centrale was found in two H. punctata, one from a cow (1.4%) and the other from vegetation (0.9%). This study represents the first evidence of the presence of A. bovis in European ticks, and reports the first detection of A. bovis and A. centrale in H. punctata, and the first finding of A. phagocytophilum and 'Ca. Midichloria mitochondrii' in I. frontalis.

Long-term transmission of measles virus in Central and continental Western Europe.

The World Health Organization (WHO) has adopted an elimination goal for measles and rubella, which is supposed to be met in the WHO European Region (EUR) by 2015. For verification of elimination, it is required that the genotyping data of detected measles viruses provide evidence for the interruption of endemic transmission. In order to record and assess the extent of endemic measles virus (MV) circulation in a part of the EUR, we analyzed transmission chains of the epidemiologically most relevant MV variants identified in Central and continental Western Europe (CCWE) from 2006 to 2013. Based on MV sequence data deposited in the WHO global database for molecular surveillance of measles (MeaNS), the circulation period was calculated for each MV variant at the country-level and for the entire region of CCWE. The MV variants "D5-Okinawa," "D4-Hamburg," "D4-Manchester," and "D8-Frankfurt-Main" spread widely in CCWE; they caused large and long-lasting outbreaks with secondary spread that resulted in additional outbreaks. Nation-wide outbreaks (epidemics) with thousands of measles cases occurred in four countries (Switzerland, France, Bulgaria, and Romania) and were characterized by continuous detection of the same MV variant for more than 12 months suggesting endemic transmission. In the entire region of CCWE, the circulation period of the four predominant MV variants ranged from 18 to 44 months. The long-lasting MV transmission which affected predominantly unvaccinated individuals in different hard-to-reach groups and in the general population is not consistent with the measles elimination goal. Additional efforts are necessary to meet the elimination target in the EUR.

Características de las interacciones farmacológicas en una unidad de cuidados intensivos de pediatría / Characteristics of drug interactions in a pediatric intensive care unit

Introduction: The aim of this study is to calculate the theoretical frequency of potential drug interactions (PDI) and their characteristics in the therapeutic plan of hospitalized patients in a Pediatric Intensive Care Unit (PICU). Patients and Methods: An observational study was conducted which analyzed PICU prescriptions between September and November 2011. The inclusion criteria included to be hospitalized in a PICU, requirements of at least 3 drugs, except those topically applied, either gender, no age limit, no hospital stay required. The Micromedex ® 2.0 program was used to detect and classify PDI. Results: Of 223 patients, 100 met inclusion criteria, 610 prescriptions were analyzed and 815 drugs were prescribed. 1,240 PDI were detected in 44 patients; 12 patients received more than 10 drugs each, presenting 1,162 PDI (93.7% of total PDI). 8 patients were hospitalized for more than 10 days, presenting 1,035 PDI (83.5% of total PDI). According to PDI theoretical severity, 37.5% were high, 51.7% moderate, 6.7% low and 4.1% contraindicated. The therapeutic group most involved was antimicrobials (17.6%) and the most frequently involved individual drugs were chloral hydrate (15.9%), midazolam (14.1%) and vecuronium (13.4%). Conclusion: PDI were more frequent in patients associated with major polypharmacy and longer hospital stay.

Introducción: El objetivo de éste estudio fue medir la frecuencia teórica de interacciones farmacológicas probables (IF) y sus características en los esquemas terapéuticos de los pacientes hospitalizados una Unidad de Cuidados Intensivos Pediátricos (UCIP). Pacientes y Método: Estudio observacional que analizó las prescripciones médicas en UCIP entre septiembre y noviembre del año 2011. Criterios de inclusión fueron estar hospitalizados en la UCIP, tener prescripciones que incluyan a lo menos 3 medicamentos, excepto aquellos de aplicación tópica, ambos sexos, sin límite de edad, ni estadía hospitalaria. Se utilizó el programa Micromedex 2.0® para la detección y clasificación de las IF. Resultados: De 223 pacientes, 100 cumplieron criterio de inclusión, en quienes se analizaron 610 prescripciones médicas, donde se indicaron 815 fármacos. Se detectaron 1.240 IF en 44 pacientes. Doce pacientes recibieron más de 10 fármacos cada uno, registrándose en ellos 1.162 IF (93,7% de las IF). Ocho pacientes estuvieron más de 10 días hospitalizados, concentrando 1.035 IF (83,5% de las IF). Según severidad teórica de las IF, se encontró 37,5% mayores, 51,7% moderadas, 6,7% menores y 4,1% contraindicadas. El grupo terapéutico más implicado fueron los antimicrobianos (17,6%) y los fármacos individuales más frecuentemente involucrados fueron hidrato de cloral (15,9%), midazolam (14,1%) y vecuronio (13,4%). Conclusión: Las IF fueron más frecuentes en pacientes con mayor polifarmacia y estadía más prolongada.

Measles virus spread initiated at international mass gatherings in Europe, 2011.

Three parallel transmission chains of measles virus (MV) variant 'D8-Villupuram' (D8-V) originated from two coinciding international mass gathering (MG) events in Rimini, Italy, in June 2011. MV D8-V was independently introduced into Germany by two unvaccinated persons, and into Slovenia by one unvaccinated person who had attended these events. Secondary spread of D8-V was restricted to two generations of transmission in Slovenia as well as in Germany where the virus was further disseminated at another MG. Serological and epidemiological investigation of the D8-V-associated German and Slovenian cases revealed different antibody responses and age distributions. Primary infected young persons between 11 and 27 years-old were affected in Germany, whereas the group of Slovenian cases comprised adults aged from 28 to 47 years and a high proportion (9/14; 64%) of patients with secondary vaccine failure (SVF). Our study demonstrates that monitoring of MV transmission chains in an international context and adequate serological investigation of cases with remote vaccination can contribute to identify susceptibility gaps.

Mumps virus infection in vaccinated patients can be detected by an increase in specific IgG antibodies to high titres: a retrospective study.

Mumps outbreaks in highly vaccinated populations with genotype G have been reported repeatedly. Detection of these outbreaks can be difficult in a setting with relatively high vaccination coverage when acute cases of mumps are routinely diagnosed by IgM serology since this marker is not reliable for diagnosis of mumps re-infection. To learn whether diagnostic tests performed in a large private laboratory may be useful to detect mumps outbreaks retrospectively, we reviewed the results of almost 7000 mumps tests. Two groups were compared: group 1 comprised of 3438 samples from patients submitted by physicians and clinicians (it was assumed that these patients visited their doctor due to acute disease). Group 2 comprised of 3398 samples submitted from company medical officers and occupational physicians. Since these patients usually attend for routine check-ups and certification of immunity to vaccine-preventable diseases, these samples comprised a control group. From July 2010 to May 2011, a mumps virus outbreak with more than 300 cases occurred in Bavaria, Southeast Germany. Our study includes samples received for serological mumps tests from January 2009 until December 2011 (36 months). The two groups were analysed with regard to the number of IgM-positive cases per month and the level of IgG titre. We found a marked increase for both parameters in group 1 during the time of the outbreak, while the samples submitted by the occupational medical physicians did not display significant alterations. These parameters reflect the outbreak with high accuracy, indicating that a retrospective analysis of IgG titres may be a useful tool for detection of mumps outbreaks when, as was the case in Germany, (i) a nationwide notification system has not been implemented and (ii) a highly vaccinated population is affected.

Measles outbreak spreading from the community to an anthroposophic school, Berlin, 2011.

Between April and July 2011 there was an outbreak of measles virus, genotype D4, in Berlin, Germany. We identified 73 case-patients from the community and among students of an anthroposophic school, who participated in a 4-day school trip, as well as their family and friends. Overall, 27% were aged ≥ 20 years, 57% were female and 15% were hospitalized. Of 39 community case-patients, 38% were aged ≥ 20 years, 67% were female and 63% required hospitalization. Unvaccinated students returning from the school trip were excluded from school, limiting transmission. Within the group of 55 school-trip participants, including 20 measles case-patients, a measles vaccine effectiveness of 97.1% (95% confidence interval 83.4-100) for two doses was estimated using exact Poisson regression. Our findings support school exclusions and the recommendation of one-dose catch-up vaccination for everyone born after 1970 with incomplete or unknown vaccination status, in addition to the two-dose routine childhood immunization recommendation.

Transmission and molecular characterisation of wild measles virus in Romania, 2008 to 2012.

Molecular characterisation of measles virus is a powerful tool for tracing transmission. Genotyping may prove the absence of endemic circulation of measles virus, i.e. transmission for more than 12 months, which is one of the criteria for verifying elimination of the disease. We have genetically characterised measles viruses detected in Romania from 2008 to 2012, focusing on the recent outbreaks from 2010 to 2012 that affected mainly groups with limited access to healthcare and schools. The findings emphasise the importance of genotyping during the different phases of an outbreak. A total of 8,170 cases were notified, and 5,093 (62%) of the 7,559 possible cases were serologically confirmed. RT-PCR was performed for 104 samples: from the 101 positive samples obtained from sporadic measles cases or clusters from different counties, 73 were genotyped. Sporadic measles cases associated with D4 and D5 viruses were observed from2008 to 2009. Genotype D4-Manchester was predominant in 2011 and 2012. In addition, the related variant D4-Maramures and MVs/Limoges.FRA/17.10[D4] and a few D4-Hamburg strains were detected. The detection of several distinct MV-D4 genotypes suggests multiple virus importations to Romania. The outbreak associated with D4 genotype is the second largest outbreak in Romania in less than 10 years.

[Molecular surveillance shows progress in measles elimination process]. / Molekulare Surveillance belegt Fortschritt im Eliminationsprozess der Masern.

Measles is a severe disease caused by infection with the measles virus. Complications after the onset of infection lead to 1-3 fatalities per 1,000 cases in industrialized countries. If more than 95 % of the global population were vaccinated twice with the measles, mumps, and rubella (MMR) vaccine, measles could be eliminated worldwide. The elimination of measles and rubella should be reached in the WHO Europe region in 2015. One important criterion for elimination of the measles virus consists in the analysis of the duration of transmission chains initiated by the import of measles virus. To assign measles viruses to outbreaks and transmission chains, genetic characterization is necessary. These investigations have been performed continually at the National Reference Center Measles, Mumps, Rubella since 1999, when the German Intervention Program was launched. This article summarizes our experiences with measles virus genotyping and new developments with respect to measles elimination in Germany.

Appearance of a novel measles G3 strain in multiple European countries within a two month period, 2010.

During late 2010, a previously unrecognised strain of measles genotype G3 virus was identified in five different European countries by the World Health Organization Measles and Rubella Laboratory Network.Apart from one, none had a travel history to south-east Asia, the usual source of G3 viruses, although epidemiological links could be established between some of the cases. This case series illustrates the value of genotyping and sequencing in tracking measles infections, and identifying otherwise unrecognised chains of transmission.

Spotlight on measles 2010: An epidemiological overview of measles outbreaks in Poland in relation to the measles elimination goal.

The objective of this study was to describe transmission chains of measles observed in Poland during 2008-2009. A decade ago, the incidence of measles in Poland declined and approached one case per million inhabitants one of the World Health Organization's criteria for measles elimination. Following a period of very few reported measles cases (2003 to 2005), an increase in incidence was observed in 2006. Since then, the incidence has constantly exceeded one case per million inhabitants. Of 214 measles cases reported in 2008 and 2009 in Poland, 164 (77%) were linked to 19 distinct outbreaks, with 79% of cases belonging to the Roma ethnic group. Outbreaks in the non-Roma Polish population had different dynamics compared to those in the Roma population. On average, measles outbreaks in Roma communities involved 10 individuals, seven of whom were unvaccinated, while outbreaks in the non-Roma Polish population involved five individuals, half of whom were incompletely vaccinated. The majority of outbreaks in Roma communities were related to importation of virus from the United Kingdom. In six outbreaks, the epidemiologic investigation was confirmed by identification of genotype D4 closely related to measles viruses detected in the United Kingdom and Germany. Our data indicate that Poland is approaching measles elimination, but measles virus circulation is still sustained in a vulnerable population. More efforts are needed to integrate the Roma ethnic group into the Polish healthcare system and innovative measures to reach vulnerable groups should be explored.

Measles outbreak linked to a minority group in Austria, 2008.

We report on a measles outbreak originating in an anthroposophic community in Austria, 2008. A total of 394 (94.9%) cases fulfilled the outbreak case definition including 168 cases affiliated to the anthroposophic community. The source case was a school pupil from Switzerland. The Austrian outbreak strain was genotype D5, indistinguishable from the Swiss outbreak strain. A school-based retrospective cohort study in the anthroposophic school demonstrated a vaccine effectiveness of 97.3% in pupils who had received a single dose of measles-containing vaccine and 100% in those who had received two doses. The vaccination coverage of the cases in the anthroposophic community was 0.6%. Of the 226 outbreak cases not belonging to the anthroposophic community, the 10-24 years age group was the most affected. Our findings underline the epidemiological significance of suboptimal vaccination coverage in anthroposophic communities and in older age groups of the general population in facilitating measles virus circulation. The findings of this outbreak investigation suggest that the WHO European Region is unlikely to achieve its 2010 target for measles and rubella elimination.