Lifting COVID-19 mitigation measures in Spain (May–June 2020 / La desescalada de las medidas de mitigación contra el COVID-19 en España (mayo–junio 2020)

Introduction: The state of alarm was declared in Spain due to the COVID-19 epidemic on March 14, 2020, and established population confinement measures. The objective is to describe the process of lifting these mitigation measures. Methods: The Plan for the Transition to a New Normality, approved on April 28, contained four sequential phases with progressive increase in socio-economic activities and population mobility. In parallel, a new strategy for early diagnosis, surveillance and control was implemented. A bilateral decision mechanism was established between the Spanish Government and the autonomous communities (AC), guided by a set of qualitative and quantitative indicators capturing the epidemiological situation and core capacities. The territorial units were established ad-hoc and could be from Basic Health Zones to entire AC. Results: The process run from May 4 to June 21, 2020. AC implemented plans for reinforcement of core capacities. Incidence decreased from a median (50% of territories) of 7.4 per 100,000 in 7 days at the beginning to 2.5 at the end. Median PCR testing increased from 53% to 89% of suspected cases and PCR total capacity from 4.5 to 9.8 per 1000 inhabitants weekly; positivity rate decreased from 3.5% to 1.8%. Median proportion of cases with traced contacts increased from 82% to 100%. Conclusion: Systematic data collection, analysis, and interterritorial dialogue allowed adequate process control. The epidemiological situation improved but, mostly, the process entailed a great reinforcement of core response capacities nation-wide, under common criteria. Maintaining and further reinforcing capacities remained crucial for responding to future waves.(AU)

Introducción: El 14 de marzo de 2020 España declaró el estado de alarma por la pandemia por COVID-19 incluyendo medidas de confinamiento. El objetivo es describir el proceso de desescalada de estas medidas. Métodos: Un plan de transición hacia una nueva normalidad, del 28 de abril, incluía 4 fases secuenciales incrementando progresivamente las actividades socioeconómicas y la movilidad. Concomitantemente, se implementó una nueva estrategia de diagnóstico precoz, vigilancia y control. Se estableció un mecanismo de decisión bilateral entre Gobierno central y comunidades autónomas (CCAA), guiado por un panel de indicadores cualitativos y cuantitativos de la situación epidemiológica y las capacidades básicas. Las unidades territoriales evaluadas comprendían desde zonas básicas de salud hasta CCAA. Resultados: El proceso se extendió del 4 de mayo al 21 de junio y se asoció a planes de refuerzo de las capacidades en las CCAA. La incidencia disminuyó de una mediana inicial de 7,4 por 100.000 en 7 días a 2,5 al final del proceso. La mediana de pruebas PCR aumentó del 53% al 89% de los casos sospechosos, y la capacidad total de 4,5 a 9,8 pruebas semanales por 1.000 habitantes; la positividad disminuyó del 3,5% al 1,8%. La mediana de casos con contactos trazados aumentó del 82% al 100%. Conclusión: La recogida y análisis sistemático de información y el diálogo interterritorial logaron un adecuado control del proceso. La situación epidemiológica mejoró, pero sobre todo, se aumentaron las capacidades, en todo el país y con criterios comunes, cuyo mantenimiento y refuerzo fue clave en olas sucesivas.(AU)

Enfermedades asociadas a flebovirus trasmitidos por flebótomos: ¿qué riesgo tenemos en España? / Phlebovirus-associated diseases transmitted by phlebotominae in Spain: Are we at risk?

Los virus del género Phlebovirus, transmitidos por dípteros de la familia Psychodidae, son una causa de síndrome febril autolimitado durante el verano-otoño en los países mediterráneos. En el caso del virus Toscana, pueden ser causa de meningitis y meningoencefalitis. En España se ha detectado la presencia de los virus Toscana, Granada, Nápoles, Sicilia, Arbia y Arrabida-like. La presencia casi generalizada de vectores del género Phlebotomus, especialmente de Phlebotomus perniciosus, en los que se han detectado varios de estos virus, hace muy probable que aparezcan de manera regular infecciones en humanos en nuestro país, siendo este riesgo moderado para el virus Toscana y bajo para el resto, en las zonas con mayor actividad del vector. La mayor parte de las enfermedades pasarían inadvertidas y solo el virus Toscana puede tener un mayor impacto por la aparición de casos graves.(AU)

The genera Phlebovirus transmitted by Diptera belonging to the Psychodidae family are a cause of self-limited febrile syndrome in the Mediterranean basin in summer and autumn. Toscana virus can also cause meningitis and meningoencephalitis. In Spain, Toscana, Granada, Naples, Sicily, Arbia and Arrabida-like viruses have been detected. The almost widespread distribution of Phlebotomus genus vectors, and especially Phlebotomus perniciosus, in which several of these viruses have been detected, makes it very likely that there will be regular human infections in our country, with this risk considered moderate for Toscana virus and low for the other ones, in areas with the highest vector activity. Most of the infections would be undiagnosed, while only Toscana virus would have a greater impact due to the potential severity of the illness.(AU)

Widespread Detection of Multiple Strains of Crimean-Congo Hemorrhagic Fever Virus in Ticks, Spain.

Human cases of Crimean-Congo hemorrhagic fever (CCHF) were first detected in Spain in 2016. National human and animal health authorities organized a large, multidisciplinary study focusing on ticks as sentinels to determine the nationwide distribution of ticks with CCHF virus. Ticks were collected from animals and vegetation, samples pooled (12,584 ticks; 4,556 pools), and molecular methods used to look for the virus. We detected the virus in 135 pools from most of the regions studied, indicating that it is widespread in Spain. We found sequences of CCHF virus genotypes I, III, and IV in the tick species collected, most commonly in Hyalomma lusitanicum, suggesting this tick has a prominent role in the virus's natural cycle. The red deer (Cervus elaphus) was the host that most frequently yielded positive ticks. Our study highlights the need for larger studies in Spain to ascertain the complete risk to public health.

Intravenous colistin sulphomethate sodium for therapy of infections due to multidrug-resistant gram-negative bacteria.

OBJECTIVE: To assess the efficacy and toxicity of intravenous colistin in the treatment of infections due to multidrug-resistant gram-negative bacteria. METHODS: Retrospective cohort study. RESULTS: Sixty patients received colistin sulphomethate sodium (mean dose, 4.4mg/kg/day; median duration, 20days). The main infections were pneumonia or tracheobronchitis (63.3%), intra-abdominal (10%), urinary tract (8.3%), and surgical site infection (6.6%), primary bacteremia (5%), catheter infection (3.3%), meningitis (1.6%), and soft-tissue infection (1.6%). The responsible bacteria were Acinetobacter spp. (50%), P. aeruginosa (23.3%), K. pneumoniae (13.3%), Enterobacter spp. (10%), E. coli (1.6%), and S. maltophilia (1.6%). Eight patients (13%) received colistin monotherapy, and 52 (87%) received combination therapy with other antibiotics such as beta-lactams (15 cases), aminoglycosides (14), beta-lactams and aminoglycosides (15), or ciprofloxacin (8). A favourable response was observed in 43 cases (71.7%). Overall mortality was 26.7%. Despite the common use of combination therapy with aminoglycosides (48%), nephrotoxicity during colistin therapy was observed in only 10.9% of patients; most of them had previous renal failure. CONCLUSION: Colistin appears to be an effective and safe drug for therapy of severe infections due to multidrug-resistant gram-negative bacteria. Despite the concomitant use of aminoglycosides in a high proportion of patients, renal toxicity was an uncommon adverse event.

Candidemia in pediatric patients with congenital heart disease.

Candidemia is an important problem in pediatrics. In our hospital, highest candidemia rates were documented among children with congenital heart disease (CHD). A series was conducted to describe the clinical and mortality features of candidemia in these patients. Fifty-two cases (1988-2000) included very young infants (median age, 2 months) who received long-term antibiotic treatment (median, 20.5 days). Candida parapsilosis predominated (54%). Endovascular infections occurred in 11.5%. In-hospital mortality was 39% and related mortality 14%. Maintenance of catheter (odds ratio [OR], 6.0; 95% confidence interval [CI], 1.0-37.2; P = .05) and severity of patients as measured with the Pediatric Risk Score of Mortality I (OR, 1.1, 95% CI, 1.0-1.3; P = .05) were independently associated with mortality. In summary, candidemia in children with CHD is diagnosed to very young infants with prolonged antibiotic therapy. Mortality is high but, in most cases, is not related to candidemia. Optimal management may include exclusion of endocarditis, early antifungal treatment, and catheter removal.

Secular trends of candidemia in a large tertiary-care hospital from 1988 to 2000: emergence of Candida parapsilosis.

OBJECTIVE: To analyze the secular trends of candidemia in a large tertiary-care hospital to determine the overall incidence, as well as the incidence by ward and by species, and to detect the occurrence of outbreaks. DESIGN: Retrospective descriptive analysis. Secular trends were calculated using the Mantel-Haenszel test. SETTING: A large tertiary-care referral center in Spain with a pediatric intensive care unit (ICU) to which more than 500 children with congenital cardiac disease are admitted annually. PATIENTS: All patients with candidemia occurring from 1988 to 2000 were included. Cases were identified from laboratory records of blood cultures. RESULTS: There were 331 episodes of candidemia. The overall incidence of nosocomial candidemia was 0.6 episode per 1,000 admissions and remained stable throughout the study period (P = .925). The species most frequently isolated was Candida albicans, but the incidence of C. parapsilosis candidemia increased (P = .035). In the pediatric ICU, the incidence of C. parapsilosis was 5.6 episodes per 1,000 admissions and it was the predominant species. Outbreaks occurred occasionally in the pediatric ICU, suggesting nosocomial transmission. CONCLUSIONS: During this 13-year period, the incidence of candidemia remained stable in this hospital, but C. parapsilosis increased in frequency. Occasional outbreaks of candidemia suggested nosocomial transmission of Candida species.