Clinical characteristics and outcomes of diabetic patients who were hospitalised with 2009 pandemic influenza A H1N1 infection.

OBJECTIVES: To describe demographic and clinical data and outcomes of severe cases of 2009 pandemic influenza A H1N1 (pH1N1) infections for persons with diabetes. METHODS: We selected all person with diabetes (N = 252) among severe laboratory confirmed cases reported to the Spanish Surveillance System for detection of pH1N1 from June through December, 2009. One patient without diabetes matched by age and sex was selected. Collected variables included demographic characteristics, underlying medical conditions, outcome, clinical course and treatment. RESULTS: Among those suffering diabetes only 15.9% did not report any other underlying condition. 38% of diabetic patients and 27.4% of non diabetic patients were admitted to ICU (p = 0.008). Thirty subjects suffering diabetes and fifteen without the disease died (11.9% vs. 6%[p = 0.019]). Multivariable analysis showed that the independent risk factors for ICU admission or death were suffering cardiovascular disease (OR = 2.28), morbid obesity (OR = 2.08) and antiviral treatment started after 48 h of onset of symptoms (OR = 1.89). Suffering diabetes was not independent risk factors for ICU admission or death after adjusting for covariates. CONCLUSIONS: The worse outcome among diabetes sufferers could be a consequence of the higher prevalence of comorbid underlying medical conditions but not diabetes itself. Further prospective studies are needed to verify these results.

Actividades de vigilancia epidemiológica durante la pandemia de gripe (H1N1) 2009 en España. Reflexiones un años después / Epidemiological surveillance activities during the 2009 influenza pandemic in Spain. Lessons learnt one year after

En este artículo se revisan las actuaciones llevadas a cabo en España en materia de vigilancia epidemiológica durante la pandemia de gripe y las recomendaciones de ellas derivadas en los diferentes momentos de la evolución de la misma. El funcionamiento del Sub-comité de Vigilancia, contemplado en el Plan Nacional de Prepara-ción y Respuesta ante una pandemia de gripe, fue clave para la coor-dinación de estas actividades de vigilancia. Este Subcomité se activó de forma inmediata tras la declaración de la alerta y su papel también se describe en este trabajo. La existencia del Plan permitió una respuesta rápida y coordina-da tras la declaración de la alerta. La vigilancia epidemiológica y virológica de la gripe hubo de ir adaptándose a una situación cam-biante, y se pusieron en marcha sistemas adicionales a los de la vigi-lancia habitual de la gripe, tales como la vigilancia individualizada de casos en la comunidad y de casos graves y mortales. Entre las lecciones aprendidas destacan la necesidad de fortale-cer el análisis de los datos que se recogen durante una alerta, la nece-sidad de favorecer el intercambio de información entre los profesio-nales de salud pública y los asistenciales, y de reforzar la capacidad de respuesta para poder disponer de estructuras de salud pública fuertes y consolidadas ante futuras alertas sanitarias(AU)

In this article the actions taken in the area of epidemiological sur-veillance in Spain during the influenza pandemic and the recommen-dations drawn from them during the progression of the pandemic are reviewed. The performance of the Surveillance Subcommittee established in the National Influenza Preparedness and Response Plan was cen-tral to the coordination of these activities. The Surveillance Subcom-mittee was immediately activated when the alert was issued. Its role is also described in this review. The existence of a National Plan allowed a rapid and coordinated response after the alert declaration. The epidemiological and virolo-gical surveillance of the influenza pandemic was adapted to an evol-ving situation. In addition to routine influenza monitoring systems, new surveillance systems were put in place such as a case-based sur-veillance for community influenza cases and a case-based survei-llance for severe cases and deaths due to the pandemic. Among the lessons learned from this pandemic, we would high-light the need to strengthen the timely analysis of data collected during an alert, the need to promote the exchange of information among public health and health care professionals, and to strengthen the response capacity in order to have resilient and consolidated public health structures for future health alerts(AU)

Bases epidemiológicas para la toma de decisiones sobre medidas de salud pública (no farmacológicas) durante la respuesta a la pandemia de gripe (H1N1) 2009 / Monitoring and non pharmacologic measures during a pandemic virus (H1N1) 2009 in Spain

Las medidas de salud pública no farmacológicas se utilizan para reducir la exposición de las personas susceptibles a un agente infec-cioso. Se recomiendan al comienzo de una pandemia cuando la transmisión comienza y no se conocen las características del nuevo virus. El Plan Nacional de Preparación y Respuesta ante una Pande-mia de Gripe desarrolla la aplicación de estas medidas, recomendan-do la constitución de un Comité Asesor para su aplicación, multidis-ciplinar en su composición, con el fin de analizar el contexto epide-miológico y social en el que se desarrolla la pandemia y proponer medidas de salud pública según su evolución. En este artículo se describen las medidas de aislamiento, cuaren-tena y cierre de escuelas, que tienen el objetivo de reducir la difusión del virus en la población, y se revisan las bases teóricas que ayudan comprender el impacto de su aplicación. Las medidas de salud pública revisadas en este artículo reducen la transmisión del virus por lo que tienen que ser consideradas en la respuesta a una pandemia de gripe. El impacto sobre la salud depen-derá de la rapidez con que se tomen y del grado de aceptación y seguimiento que consigan. Los planes de respuesta deberán reco-mendar su uso en función de la gravedad ylas características del nue-vo virus pandémico. El análisis de los datos debería ser considerado como parte de la respuesta, ya que la información recogida y su análisis será la clave para asesorar a las autoridades sanitarias sobre las medidas que debe-rían adoptar(AU)

Nonpharmacological public health measures are used to reduce exposure of susceptible persons to an infectious agent. Its use is recommended at the start of a pandemic, when the transmission begins, and the characteristics of the new virus are unknown. The National Plan for Preparedness and Response to Pandemic Influenza included the application of these measures, recommending the esta-blishment of an Advisory Committee for implementation, with a multidisciplinary composition. The mandate at this Committee is to analyze the epidemiological and social context in confronting the pandemic and to propose public health measures according to their evolution. This article describes isolation, quarantine and closure of schools measures, aiming to reduce the spread of the virus in the population. It also reviews the epidemiological parameters that help to unders-tand the impact of its implementation. The public health measures reviewed in this paper reduce trans-mission of the virus, and they have to be considered in response to an influenza pandemic. The impact on health will depend on how quickly they are taken and how people accept and follow them. Res-ponse plans should recommend its use, depending on the severity and characteristics of the new pandemic virus. The data analysis should be considered as part of the response, because the information collection and analysis will be key to advi-sing health authorities on what measures should be adopted(AU)

Vigilancia individualizada de los casos iniciales de infección por gripe pandémica (H1N1) 2009 en España, abril-junio 2009 / Enhanced surveillance of initial cases of pandemic influenza (H1N1) 2009 infection in Spain, April-June 2009

Fundamentos: En abril de 2009 se inició en España una nueva estrategia de vigilancia con el objetivo de detectar los casos originados por el virus pandémico (H1N1) 2009 y de implementar las medidas de control adecuadas para contener su transmisión. Se describen las características clínicas y epidemiológicas de los casos confirmados en España notificados por la Red Nacional de Vigilancia Epidemiológica desde el 24 Abril al 30 Junio 2009. Métodos: Como parte de la respuesta inicial de vigilancia a la pandemia, a nivel nacional se recogió información clínica y epide-miológica individualizada de todos los casos en investigación de infección por virus pandémico (H1N1) 2009, así como de sus contactos. Resultados: De los 717 casos confirmados el 91% fueron notificados por 5 Comunidades Autónomas. A 15 de junio de 2009 el 49,1% de los casos pertenecían a brotes en centros educativos. No se detectaron brotes nosocomiales. La mediana de período de incubación fue de 3 días. El 88% de los casos tenía menos de 30 años y el 24,9% eran importados. Los síntomas más frecuentes fueron tos (92%) y fiebre (81,8%). La mediana de duración de síntomas fue de 5 días. Trece casos requirieron ingreso hospitalario y uno falleció. Conclusiones: Durante los primeros meses de pandemia los casos de gripe pandémica presentaron un cuadro leve similar al de la gripe estacional que afectó mayoritariamente a niños y adultos jóvenes. A finales de junio 2009 la aparición de brotes en diferentes colectivos reflejaba la penetración del virus pandémico en la comunidad y el inicio de su circulación(AU)

Background: In April 2009, a new surveillance strategy for the detection of cases of pandemic influenza (H1N1) 2009 infection and for the implementation of appropriate control measures to contain its transmission was initiated in Spain. We describe the clinical and epi-demiological characteristics of confirmed cases in Spain notified by the National Epidemiological Surveillance Network from April 24 to June 30, 2009. Methods: As part of the initial surveillance response to the pan-demic, case-based clinical and epidemiological information was co-llected nationwide on cases under investigation for pandemic virus (H1N1) 2009 infection and their contacts. Results: Of 717 confirmed cases, 91% were notified by 5 Auto-nomous Communities. As of June 15, 49.1% of cases belonged to school outbreaks. No nosocomial outbreaks were detected. The me-dian incubation period was 3 days. Eighty-eight percent of cases were under the age of 30 years, and 24.9% were imported. The most frequent symptoms were cough (92%) and fever (81.8%). The me-dian duration of symptoms was 5 days. Thirteen cases required hos-pitalization and one died. Conclusions: During the first months of the pandemic, pande-mic influenza cases experienced a mild illness similar to seasonal influenza, predominantly affecting children and young adults. By the end of June 2009, the detection of outbreaks in different settings indicated the diffusion of the pandemic virus into the community and the start of its circulation(AU)

Casos de infección por gripe pandémica (H1N1) 2009 hospitalizados en cuidados intensivos en España: factores asociados a riesgo de muerte, abril 2009-enero2010 / Critically ill patients with 2009 pandemic influenza A (H1N1) infection in Spain: factors associated with death, April 2009-January 2010

Fundamento: El análisis de los casos graves de gripe pandémica es necesario para identificar grupos de población vulnerables y adecuar las políticas de prevención y control. Se analizan las características clínicas y epidemiológicas así como los factores asociados a riesgo de muerte en los casos de infección por virus pandémico (H1N1) 2009 hospitalizados en unidades de cuidados intensivos (UCI) en España y notificados entre el 24 de abril de 2009 y el 31 de enero de 2010. Método:En el marco de la estrategia nacional de vigilancia de casos hospitalizados por gripe pandémica, se recogió a nivel nacional informa-ción clínica y epidemiológica individualizada de todos los casos hospitali-zados en UCI por infección por virus pandémico (H1N1) 2009. Resultados:De los 1.231 casos ingresados en una UCI fallecieron 271 (letalidad: 22%). La mediana de edad fue 40 años (rango: 0-90). Un total de 838 (76,3%) pacientes presentaban alguna patología subyacente, siendo la respiratoria la más frecuente (34,1%), seguida en adultos de la obesidad mórbida (18,8%). Un 93,1% recibió tratamiento antiviral y un 25,6% (n=231) lo recibió en 48 horas desde el inicio de síntomas. En el análisis multivariante el cáncer (OR 2,71; IC95% 1,44-5,1), las inmunodeficiencias (OR 2,25; IC95% 1,29-3,92) y la obesidad mórbida (OR 1,79; IC95% 1,13-2,85) estaban asociados significativamente a muerte en los adultos. Conclusión:La caracterización de los casos graves de gripe pandé-mica ha sido clave para identificar como factores de riesgo para sufrir complicaciones y muerte por gripe, la existencia de cáncer e inmunodefi-ciencias y, por primera vez, la obesidad mórbida en personas adultas(AU)

Background: It is necessary to analyse the severe cases of pandemic influenza infection in order to identify vulnerable populations and adapt prevention and control policies accordingly. We analysed the clinical and epidemiological characteristics and risk factors associated with death in patients with 2009 pandemic influenza A (H1N1) infection hospitalised in intensive care units (ICUs) in Spain and reported from 24 April 2009 to 31 January 2010. Methods: As part of the national strategy for surveillance of hospita-lized cases with pandemic influenza, cased-based clinical and epidemiolo-gical information on all cases admitted to an ICU with 2009 pandemic virus (H1N1) infection was collected nationwide. Results: Of 1,231 cases admitted to ICU, 271 died (case fatality ratio, 22%). The median age was 40 years (range: 0-90). A total of 838 (76.3%) patients had an underlying risk condition, being respiratory disease the most frequently reported (34.1%), followed by morbid obesity (18.8%), in adults. Antiviral treatment was given in 93.1% patients and in 25.6% (n = 231) it was initiated within 48 hours of symptoms onset. In a multivariate analysis, cancer (OR 2.71, 95%CI 1.44 to 5.1), immunodeficiency (OR 2.25, 95%CI 1.29 - 3.92) and morbid obesity (OR 1.79, 95%CI 1.13 to 2.85) were significantly associated with death in adults. Conclusions:The characterization of severe pandemic influenza cases has been crucial in identifying as risk factors of complications and death from influenza the presence of cancer and immunodeficiencies and for the first time, morbid obesity in adults(AU)

[Epidemiological surveillance activities during the 2009 influenza pandemic in Spain: lessons learnt one year after]. / Actividades de vigilancia epidemiológica durante la pandemia de gripe (H1N1) 2009 en España: Reflexiones un año después.

In this article the actions taken in the area of epidemiological surveillance in Spain during the influenza pandemic and the recommendations drawn from them during the progression of the pandemic are reviewed. The performance of the Surveillance Subcommittee established in the National Influenza Preparedness and Response Plan was central to the coordination of these activities. The Surveillance Subcommittee was immediately activated when the alert was issued. Its role is also described in this review. The existence of a National Plan allowed a rapid and coordinated response after the alert declaration. The epidemiological and virological surveillance of the influenza pandemic was adapted to an evolving situation. In addition to routine influenza monitoring systems, new surveillance systems were put in place such as a case-based surveillance for community influenza cases and a case-based surveillance for severe cases and deaths due to the pandemic. Among the lessons learned from this pandemic, we would highlight the need to strengthen the timely analysis of data collected during an alert, the need to promote the exchange of information among public health and health care professionals, and to strengthen the response capacity in order to have resilient and consolidated public health structures for future health alerts.

[Monitoring and non pharmacologic measures during a pandemic virus (H1N1) 2009 in Spain]. / Bases epidemiológicas para la toma de decisiones sobre medidas de salud pública (no farmacológicas) durante la respuesta a la pandemia de gripe (H1N1) 2009.

Nonpharmacological public health measures are used to reduce exposure of susceptible persons to an infectious agent. Its use is recommended at the start of a pandemic, when the transmission begins, and the characteristics of the new virus are unknown. The National Plan for Preparedness and Response to Pandemic Influenza included the application of these measures, recommending the establishment of an Advisory Committee for implementation, with a multidisciplinary composition. The mandate at this Committee is to analyze the epidemiological and social context in confronting the pandemic and to propose public health measures according to their evolution. This article describes isolation, quarantine and closure of schools measures, aiming to reduce the spread of the virus in the population. It also reviews the epidemiological parameters that help to understand the impact of its implementation. The public health measures reviewed in this paper reduce transmission of the virus, and they have to be considered in response to an influenza pandemic. The impact on health will depend on how quickly they are taken and how people accept and follow them. Response plans should recommend its use, depending on the severity and characteristics of the new pandemic virus. The data analysis should be considered as part of the response, because the information collection and analysis will be key to advising health authorities on what measures should be adopted.

[Enhanced surveillance of initial cases of pandemic influenza (H1N1) 2009 infection in Spain, April-June 2009]. / Vigilancia individualizada de los casos iniciales de infección por gripe pandémica (H1N1) 2009 en España, Abril-Junio 2009.

BACKGROUND: In April 2009, a new surveillance strategy for the detection of cases of pandemic influenza (H1N1) 2009 infection and for the implementation of appropriate control measures to contain its transmission was initiated in Spain. We describe the clinical and epidemiological characteristics of confirmed cases in Spain notified by the National Epidemiological Surveillance Network from April 24 to June 30, 2009. METHODS: As part of the initial surveillance response to the pandemic, case-based clinical and epidemiological information was collected nationwide on cases under investigation for pandemic virus (H1N1) 2009 infection and their contacts. RESULTS: Of 717 confirmed cases, 91% were notified by 5 Autonomous Communities. As of June 15,49.1% of cases belonged to school outbreaks. No nosocomial outbreaks were detected. The median incubation period was 3 days. Eighty-eight percent of cases were under the age of 30 years, and 24.9% were imported. The most frequent symptoms were cough (92%) and fever (81.8%). The median duration of symptoms was 5 days. Thirteen cases required hospitalization and one died. CONCLUSIONS: During the first months of the pandemic, pandemic influenza cases experienced a mild illness similar to seasonal influenza, predominantly affecting children and young adults. By the end of June 2009, the detection of outbreaks in different settings indicated the diffusion of the pandemic virus into the community and the start of its circulation.

[Critically ill patients with 2009 pandemic influenza A (H1N1) infection in Spain: factors associated with death, April 2009-January 2010]. / Casos de infección por gripe pandémica (H1N1) 2009 hospitalizados en cuidados intensivos en España: factores asociados a riesgo de muerte, Abril 2009-Enero 2010.

BACKGROUND: It is necessary to analyse the severe cases of pandemic influenza infection in order to identify vulnerable populations and adapt prevention and control policies accordingly. We analysed the clinical and epidemiological characteristics and risk factors associated with death in patients with 2009 pandemic influenza A (H1N1) infection hospitalised in intensive care units (ICUs) in Spain and reported from 24 April 2009 to 31 January 2010. METHODS: As part of the national strategy for surveillance of hospitalized cases with pandemic influenza, cased-based clinical and epidemiological information on all cases admitted to an ICU with 2009 pandemic virus (H1N1) infection was collected nationwide. RESULTS: Of 1,231 cases admitted to ICU, 271 died (case fatality ratio, 22%). The median age was 40 years (range: 0-90). A total of 838 (76.3%) patients had an underlying risk condition, being respiratory disease the most frequently reported (34.1%), followed by morbid obesity (18.8%), in adults. Antiviral treatment was given in 93.1% patients and in 25.6% (n = 231) it was initiated within 48 hours of symptoms onset. In a multivariate analysis, cancer (OR 2.71, 95%CI 1.44 to 5.1), immunodeficiency (OR 2.25, 95%CI 1.29 - 3.92) and morbid obesity (OR 1.79, 95%CI 1.13 to 2.85) were significantly associated with death in adults. CONCLUSIONS: The characterization of severe pandemic influenza cases has been crucial in identifying as risk factors of complications and death from influenza the presence of cancer and immunodeficiencies and for the first time, morbid obesity in adults.

[Q fever outbreak in an urban area following a school-farm visit]. / Brote de fiebre Q en un área urbana asociado a la visita a una granja-escuela.

BACKGROUND AND OBJECTIVE: The aim of this study was to describe an outbreak of Q fever in a group of people (day care centre for mental-handicapped individuals) previously exposed to animals in a school-farm. PATIENTS AND METHOD: A retrospective cohort study among the 25 mental-handicapped individuals and the 30 workers of the centre was performed. The information about symptoms and signs and antecedents of exposition was obtained by an epidemiological survey and a clinical-epidemiological case definition was established. Serum samples from 29 people (5 mental-handicapped individuals and 24 workers) were processed for serology (Indirect Immunofluorescence against Coxiella burnetii). RESULTS: Twenty two cases of Q fever were detected. Ten were confirmed by serology (6 of them asymptomatic). More frequent symptoms were fever (100%), anorexia (81.3%), asthenia (68.8%) and non-productive cough (56.3%) among the 16 clinical cases. The risk of acute infection was 8.6 times higher in individuals of the centre that visited the school-farm (95% CI, 1.26-58.27). CONCLUSIONS: The investigation of the epidemiological antecedents allowed to detect and confirm a Q fever outbreak, to identify the probable source of exposition and to orientate the clinical and serological diagnosis.

Brote de fiebre Q en un área urbana asociado a la visita a una granja-escuela / Q fever outbreak in an urban area following a school-farm visit

Fundamento y objetivo: El objetivo del estudio ha sido describir un brote de fiebre Q en un colectivo (centro de día para discapacitados psíquicos) con antecedente de exposición a animales en una granja-escuela. Pacientes y método: Se ha realizado un estudio de cohortes retrospectivo entre los 25 usuarios y los 30 trabajadores del centro. Se recabó información referente a exposición, síntomas y signos de enfermedad y se estableció una definición clinicoepidemiológica de caso. En 29 personas (5 usuarios y 24 trabajadores del centro) se procesaron muestras para serología (inmunofluorescencia indirecta para Coxiella burnetii). Resultados: Se detectaron 22 casos de fiebre Q. Diez se confirmaron por serología (6 de ellos asintomáticos). Entre los 16 casos clínicos los síntomas más frecuentes fueron fiebre (100%), anorexia (81,3%), astenia (68,8%) y tos no productiva (56,3%). El riesgo de infección aguda se estimó en 8,6 veces mayor entre las personas del colectivo que acudieron a la granja-escuela (intervalo de confianza del 95%, 1,26-58,27). Conclusiones: La investigación de los antecedentes epidemiológicos permitió detectar y confirmar un brote de fiebre Q, identificar la probable fuente de exposición y orientar el diagnóstico clínico y serológico

Background and objective: The aim of this study was to describe an outbreak of Q fever in a group of people (day care centre for mental-handicapped individuals) previously exposed to animals in a school-farm. Patients and method: A retrospective cohort study among the 25 mental-handicapped individuals and the 30 workers of the centre was performed. The information about symptoms and signs and antecedents of exposition was obtained by an epidemiological survey and a clinical-epidemiological case definition was established. Serum samples from 29 people (5 mental-handicapped individuals and 24 workers) were processed for serology (Indirect Immunofluorescence against Coxiella burnetii). Results: Twenty two cases of Q fever were detected. Ten were confirmed by serology (6 of them asymptomatic). More frequent symptoms were fever (100%), anorexia (81.3%), asthenia (68.8%) and non-productive cough (56.3%) among the 16 clinical cases. The risk of acute infection was 8.6 times higher in individuals of the centre that visited the school-farm (95% CI, 1.26-58.27). Conclusions: The investigation of the epidemiological antecedents allowed to detect and confirm a Q fever outbreak, to identify the probable source of exposition and to orientate the clinical and serological diagnosis

[Cost-effectiveness of varicella vaccination in Spanish adolescents]. / Coste-efectividad de la vacunación contra la varicela en adolescentes en España.

INTRODUCTION: Varicella is a highly contagious disease. In Spain, in 1996, 91% of the population aged 13 years old had been infected. The complications of varicella are more frequent in adults. Herpes zoster infection can be reactivated after the initial infection in 15%. A vaccine against varicella has recently been authorized in Spain for use in individuals aged more than 13 years old with negative serology. OBJECTIVE: To determine the cost-effectiveness of vaccination of the cohort aged 13 years old in 2001 and to perform a sensitivity analysis of the parameters that are affected. MATERIAL AND METHOD: Tree decision: Decision Analysis by Tree-Age program. Probabilities and costs were calculated using Microsoft Excel. Population size was obtained from the 2001 Census of the National Institute of Statistics to which we applied the percentage of susceptibility from the seroepidemiological study in Spain. Probabilities were calculated by the Bayes Theorem, using the incidence rates by age of a country in the northern hemisphere. Hospital-related data were obtained from the minimum data set. We used the effectiveness of the vaccine licensed in the USA, with a total effectiveness of 71% and a partial effectiveness of 24%, represented by milder varicella in vaccinated individuals (breakthrough varicella). Only direct costs were considered. Costs were obtained by direct consultation of different sources. A discount rate of 3% was used. RESULTS: Varicella vaccination could prevent 27,278 cases of the disease. Prevention of one case would cost the public health system 131 Euros. DISCUSSION: This study constitutes an approach to the cost of introducing varicella vaccination in the Spanish vaccination schedule, from the payer's perspective. However, to take a decision, some unknown factors, such as the effect of vaccination on the incidence of herpes zoster, should be assessed. With currently available data, the introduction of vaccination in adolescence would seem to be the best strategy, but further studies are needed.

[Burden of disease in Spanish population under 15 years old in 1999]. / Carga de enfermedad de la población española menor de 15 años para el año 1999.

BACKGROUND AND OBJECTIVE: Burden of disease (DALYs) can help define health priorities. Our objective was to assess DALYs of those illnesses most important in Spanish children and teenagers. MATERIAL AND METHOD: We calculated DALYs components (YLL, YLD) by age groups and sex. Sources used were Spanish mortality data and WHO DALY's estimates. RESULTS: Total DALYs was 46.57/1000 habitants and it was highest in children aged less than 1 year. The first cause was represented by non-communicable diseases and the second by communicable-perinatal diseases in less than 1 year and 1-4 years and injuries in 5-14 years. CONCLUSIONS: DALYs is a good indicator to define health's population.