A community outbreak of Legionnaires' disease caused by outdoor hot tubs for private use in a hotel.

During the period October-November 2017, an outbreak of Legionnaires' disease involving 27 cases occurred in the tourist area of Palmanova (Mallorca, Spain). The majority of cases were reported by the European Centre of Disease Prevention and Control (ECDC) as travel associated cases of Legionnaires' disease (TALD). Most cases belonged to different hotel cluster alerts. No cases were reported among the local population residing in the area. All tourist establishments associated with one or more TALD cases were inspected and sampled by public health inspectors. All relevant sources of aerosol emission detected were investigated and sampled. The absence of active cooling towers in the affected area was verified, by documents and on-site. Samples from hot tubs for private use located on the terraces of the penthouse rooms of a hotel in the area were included in the study. Extremely high concentrations (> 106 CFU/l) of Legionella pneumophila, including the outbreak strain, were found in the hot tubs of vacant rooms of this hotel thus identifying the probable source of infection. Meteorological situation may have contributed to the geographical distribution pattern of this outbreak. In conclusion, hot tubs for private use located outdoors should be considered when investigating community outbreaks of Legionnaires' disease of unclear origin.

Vigilancia en salud pública: una necesidad inaplazable / Public health surveillance: a pressing need

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Predictors of advanced disease and late presentation in new HIV diagnoses reported to the surveillance system in Spain / Determinantes de enfermedad avanzada y presentación tardía en los nuevos diagnósticos de VIH notificados al sistema de vigilancia epidemiológica en España

Objective: To present surveillance data on advanced disease (AD) and late presentation (LP) of HIV in Spain and their determinants. Methods We included all new HIV diagnoses notified by the autonomous regions that consistently reported such cases throughout the period 2007-2011. Coverage was 54% of the total Spanish population. Data sources consisted of clinicians, laboratories and medical records. AD was defined as the presence of a CD4 cell count <200cells/μL in the first test after HIV diagnosis, while LP was defined as the presence of a CD4 cell count <350cells/μL after HIV diagnosis. Odds ratios and their 95% confidence intervals (OR, 95% CI) were used as the measure of association. Logistic regressions were fit to identify predictors of AD and LP. Results A total of 13,021 new HIV diagnoses were included. Among these, data on the outcome variable were available in 87.7%. The median CD4 count at presentation was 363 (interquartile range, 161-565). Overall, 3356 (29.4%) patients met the definition of AD and 5494 (48.1%) were classified as LP. Both AD and LP increased with age and were associated with male sex and infection through drug use or heterosexual contact. All immigrants except western Europeans were more prone to AD and LP. Multivariate models disaggregated by sex showed that the effect of age and region of origin was weaker in women than in men. Conclusions Despite universal health care coverage in Spain, men, immigrants and people infected through drug use or heterosexual contact seem to be experiencing difficulties in gaining timely access to HIV care (AU)

Objetivo: Se presentan los datos de vigilancia sobre enfermedad avanzada y presentación tardía de los nuevos diagnósticos de VIH en España, y sus determinantes. Métodos Se incluyeron todos los nuevos diagnósticos de VIH de 2007-2011 en el ámbito de las comunidades autónomas que notificaron de forma constante durante todo el periodo (54% de la población española). La fuente de información fueron clínicos y laboratorios. Se definió como enfermedad avanzada un recuento < 200 linfocitos CD4/μl en la primera determinación tras el diagnóstico, y como presentación tardía < 350 linfocitos CD4/μl. Se usaron la odds ratio y su intervalo de confianza del 95% como medida de asociación. Para el análisis multivariado de los factores asociados a enfermedad avanzada y presentación tardía se ajustó un modelo de regresión logística. Resultados Se incluyeron 13.021 nuevos diagnósticos, de los cuales el 87,7% tenía información de la variable de estudio. La mediana de CD4 fue de 363 (rango intercuartílico: 161-565). Durante el periodo, 3.356 pacientes (29,4%) cumplían la definición de enfermedad avanzada y 5.494 (48.1%) se clasificaron como presentación tardía. Tanto la enfermedad avanzada como la presentación tardía aumentaban con la edad, se asociaban al sexo masculino y a la transmisión a través del uso de drogas inyectadas o heterosexual. Ser inmigrante de cualquier origen, excepto de Europa Occidental, se asociaba a enfermedad avanzada y presentación tardía. Desagregando por sexo, el efecto de la edad y de la región de origen fue más débil en las mujeres que en los hombres. Conclusión A pesar de la cobertura universal en España, los hombres, los inmigrantes, los usuarios de drogas inyectadas y las personas infectadas por relaciones heterosexuales parecen tener más dificultad para acceder al seguimiento clínico (AU)

Predictors of advanced disease and late presentation in new HIV diagnoses reported to the surveillance system in Spain.

OBJECTIVE: To present surveillance data on advanced disease (AD) and late presentation (LP) of HIV in Spain and their determinants. METHODS: We included all new HIV diagnoses notified by the autonomous regions that consistently reported such cases throughout the period 2007-2011. Coverage was 54% of the total Spanish population. Data sources consisted of clinicians, laboratories and medical records. AD was defined as the presence of a CD4 cell count <200cells/µL in the first test after HIV diagnosis, while LP was defined as the presence of a CD4 cell count <350cells/µL after HIV diagnosis. Odds ratios and their 95% confidence intervals (OR, 95% CI) were used as the measure of association. Logistic regressions were fit to identify predictors of AD and LP. RESULTS: A total of 13,021 new HIV diagnoses were included. Among these, data on the outcome variable were available in 87.7%. The median CD4 count at presentation was 363 (interquartile range, 161-565). Overall, 3356 (29.4%) patients met the definition of AD and 5494 (48.1%) were classified as LP. Both AD and LP increased with age and were associated with male sex and infection through drug use or heterosexual contact. All immigrants except western Europeans were more prone to AD and LP. Multivariate models disaggregated by sex showed that the effect of age and region of origin was weaker in women than in men. CONCLUSIONS: Despite universal health care coverage in Spain, men, immigrants and people infected through drug use or heterosexual contact seem to be experiencing difficulties in gaining timely access to HIV care.

Retraso diagnóstico de la infección por el virus de la inmunodeficiencia humana en España / Delayed diagnosis of HIV infection in Spain

Objetivos Analizar el porcentaje de retraso diagnóstico (RD) de la infección por el virus de la inmunodeficiencia humana (VIH), su tendencia y factores asociados a partir de los datos procedentes del Sistema de Información de Nuevos Diagnósticos de VIH (SINIVIH) en España.Métodos Estudio descriptivo sobre las personas diagnosticadas de VIH durante 2003–2007 en las 8 comunidades autónomas (CCAA) actualmente participantes. Se definió como RD la presencia de <200CD4/μl al diagnóstico. Mediante regresión logística se obtuvieron las odds ratio (OR) y su intervalo de confianza al 95% (IC95%).Resultados Se notificaron 5.785 nuevos diagnósticos de VIH, de los que 4.798 disponían de cifra de CD4 al diagnóstico. De estos, el 37,3% cumplieron la definición de retraso. Un 19% adicional tenía entre 200–350 CD4. El porcentaje de RD era menor en mujeres que en hombres (32,9% frente a 38,6%), y mayor en heterosexuales (42,4%) y usuarios de drogas inyectadas (UDI) (40,1%) que en los hombres que mantienen relaciones sexuales con hombres (HSH) (26,7%). Ajustando por CCAA y año de diagnóstico la probabilidad de RD en españoles es mayor en hombre (OR=1,49; IC95%:1,21–1,85); en: 30–39 años (OR=2,08; IC95%:1,63–2,67), 40–49 años (OR=3,98; IC95%:3,07–5,16) y >49 años (OR=6,77; IC95%:5,10–9,00) frente a 20–29 años; y en heterosexuales (OR=1,75; IC95%:1,43–2,15) y UDI (OR=1,75; IC95%:1,38–2,22) comparados con los HSH. El RD disminuyó de 2003 a (..) (AU)

Objectives To analyse the prevalence of delayed diagnosis (DD) of human immunodeficiency virus (HIV) infection, the trends over time and its determining factors from the Newly Diagnosed HIV-infected individuals Information System (SINIVIH) data, in process of being implemented in Spain.Methods Cross-sectional study of newly diagnosed HIV-infected individuals between 2003 and 2007 in the 8 currently participating Spanish autonomous regions (AR). DD was defined as a CD4 count <200cells/μL at diagnosis. Adjusted odds ratios with 95% confidence interval were calculated using logistic regression (OR; 95%CI).Results Among the 5785 newly diagnosed HIV cases reported, 4798 had a CD4 cell count at diagnosis. Of these, 37.3% met the DD definition. An additional 19% had between 200 and 350cells/μL. The proportion of DD was lower for women than for men (32.9% versus 38.6%). According to exposure category, it was higher in heterosexuals (42.4%) and injecting drug users (IDUs) (40.1%) than in men who have sex with men (MSM) (26.7%). In the Spanish patient group, in multivariate logistic regression analyses, adjusting for AR and year of diagnosis, men were more likely to have a DD (OR=1.49; 95%CI:1.21–1.85). Compared to younger patients (20–29 years), LD was more frequent in older: 30–39 years (OR=2.08; 95% CI:1.63–2.67), 40–49 years (OR=3.98; 95% CI:3.07–5.16) and >49 years (OR=6.77; 95% CI:5.10–9.00); and compared to MSM, was more frequent in heterosexuals (OR=1.75; 95% CI:1.43–2.15) and IDUs (OR=1.75; 95% CI:1.38–2.22). DD decreased from 2003 to 2007 (OR=1.38; 95% CI:1.08–1.76). The same associated factors were found in immigrants, but with different magnitude: stronger association with men, heterosexuals and IDUs, and weaker association with older age. (..) (AU)

[Delayed diagnosis of HIV infection in Spain]. / Retraso diagnóstico de la infección por el virus de la inmunodeficiencia humana en España.

OBJECTIVES: To analyse the prevalence of delayed diagnosis (DD) of human immunodeficiency virus (HIV) infection, the trends over time and its determining factors from the Newly Diagnosed HIV-infected individuals Information System (SINIVIH) data, in process of being implemented in Spain. METHODS: Cross-sectional study of newly diagnosed HIV-infected individuals between 2003 and 2007 in the 8 currently participating Spanish autonomous regions (AR). DD was defined as a CD4 count <200cells/µL at diagnosis. Adjusted odds ratios with 95% confidence interval were calculated using logistic regression (OR; 95%CI). RESULTS: Among the 5785 newly diagnosed HIV cases reported, 4798 had a CD4 cell count at diagnosis. Of these, 37.3% met the DD definition. An additional 19% had between 200 and 350cells/µL. The proportion of DD was lower for women than for men (32.9% versus 38.6%). According to exposure category, it was higher in heterosexuals (42.4%) and injecting drug users (IDUs) (40.1%) than in men who have sex with men (MSM) (26.7%). In the Spanish patient group, in multivariate logistic regression analyses, adjusting for AR and year of diagnosis, men were more likely to have a DD (OR=1.49; 95%CI:1.21-1.85). Compared to younger patients (20-29 years), LD was more frequent in older: 30-39 years (OR=2.08; 95% CI:1.63-2.67), 40-49 years (OR=3.98; 95% CI:3.07-5.16) and >49 years (OR=6.77; 95% CI:5.10-9.00); and compared to MSM, was more frequent in heterosexuals (OR=1.75; 95% CI:1.43-2.15) and IDUs (OR=1.75; 95% CI:1.38-2.22). DD decreased from 2003 to 2007 (OR=1.38; 95% CI:1.08-1.76). The same associated factors were found in immigrants, but with different magnitude: stronger association with men, heterosexuals and IDUs, and weaker association with older age. CONCLUSIONS: DD affects almost four in every ten newly diagnosed HIV-infected individuals, and is significantly more common among men, age group over 30 years, IDUs and heterosexuals. These are associated factors both in Spanish and immigrants, but in the last group the association is stronger. Strategies to increase the perception of risk among these groups are needed, as well as the implementation of the SINIVIH in the whole country to improve and to extend the information on DD.

Estudio comparativo entre una técnica de reacción en cadena de la polimerasa en transcripción reversa en tiempo real, un método de enzimoinmunoanálisis y el cultivo shell-vial en la detección de virus gripales A y B en pacientes adultos / Comparison study of a real-time reverse transcription polymerase chain reaction assay with an enzyme immunoassay and shell vial culture for influenza A and B virus detection in adult patients

Introducción Uno de los principales problemas en el diagnóstico de la gripe es el tipo de muestra y la edad del paciente. En general, la mayoría de las técnicas diagnósticas se han mostrado muy efectivas en los pacientes pediátricos y en los aspirados nasofaríngeos. Sin embargo, su eficacia se ha mostrado mucho menor en la población adulta y los frotis faríngeos. Objetivo Se ha realizado un estudio prospectivo comparativo sobre la eficacia de una técnica de RT-PCRtr (reverse transcription polymerase chain reaction in real time ‘reacción en cadena de la polimerasa en transcripción reversa en tiempo real’) comercial, un enzimoinmunoanálisis (EIA) y el cultivo celular shell-vial (SV) en la detección de virus gripales A y B en 125 frotis faríngeos de pacientes adultos con sospecha clínica de gripe durante la temporada 2007–2008.Material y métodos A los frotis faríngeos se les realizó la detección antigénica gripal mediante un EIA dot-blot comercial. Para la RT-PCRtr se extrajo el ácido ribonucleico de 200μl de la muestra mediante el sistema de extracción automatizado EZ1 virus Mini Kit v2.0. La amplificación genómica se realizó mediante una RT-PCRtr utilizando el sistema comercial automatizado OneStep RT-PCR FluA + FluB y el SmartCycler como sistema de amplificación. Las muestras se inocularon en 2 viales de la línea celular Madin-Darby de riñón canino. El tiempo de respuesta se calculó como el transcurrido entre la llegada de la muestra hasta la obtención del resultado definitivo. Resultados El sistema EIA detectó 27 muestras positivas (21,6%), la RT-PCRtr 62 muestras positivas (49,6%) y el cultivo SV 56 muestras positivas (44,8%). De las 62 muestras positivas, el EIA detectó (..) (AU)

Introduction The age of the patients and the type of sample are major problems in the diagnosis of influenza. Most available diagnostic techniques are highly effective in pediatric patients and in nasopharyngeal aspirates. However, in the adult population and using throat swabs, these techniques are much less reliable. Aim We performed a prospective study comparing the efficacy of a commercial real-time reverse transcription PCR assay (RT-PCR) with that of an enzyme immunoassay (EIA) or shell vial culture (SV) in the detection of influenza A and B viruses in 125 throat swabs from adults with clinically suspected influenza during the 2007–2008 flu season. Material and methods Throat swabs were subjected to rapid antigen detection for influenza viruses by means of a commercial dot-blot EIA. For the RT-PCR technique, RNA was extracted from 200μL of each sample by the automated extraction system, EZ1 virus minikit (version 2.0). Genomic amplification of the extracted viral RNA was carried out using the OneStep RT-PCR FluA+FluB automated system with the SmartCycler amplification system. Each sample was inoculated into 2 SV of the MDCK cell line. Turnaround times were calculated from the time specimens were received in the laboratory to the time the result was reported to clinicians. Results The EIA system detected 27 (21.6%) positive samples, RT-PCR 62 (49.6%) positive samples, and SV 56 (44.8%) positive samples. Among the 62 positive samples, EIA detected 27 (43.5%), RT-PCR 62 (100%) and SV 56 (90.3%). With the use of RT-PCR, 38.4% of the (..) (AU)

[Comparison study of a real-time reverse transcription polymerase chain reaction assay with an enzyme immunoassay and shell vial culture for influenza A and B virus detection in adult patients]. / Estudio comparativo entre una técnica de reacción en cadena de la polimerasa en transcripción reversa en tiempo real, un método de enzimoinmunoanálisis y el cultivo shell-vial en la detección de virus gripales A y B en pacientes adultos.

INTRODUCTION: The age of the patients and the type of sample are major problems in the diagnosis of influenza. Most available diagnostic techniques are highly effective in pediatric patients and in nasopharyngeal aspirates. However, in the adult population and using throat swabs, these techniques are much less reliable. AIM: We performed a prospective study comparing the efficacy of a commercial real-time reverse transcription PCR assay (RT-PCR) with that of an enzyme immunoassay (EIA) or shell vial culture (SV) in the detection of influenza A and B viruses in 125 throat swabs from adults with clinically suspected influenza during the 2007-2008 flu season. MATERIAL AND METHODS: Throat swabs were subjected to rapid antigen detection for influenza viruses by means of a commercial dot-blot EIA. For the RT-PCR technique, RNA was extracted from 200 microL of each sample by the automated extraction system, EZ1 virus minikit (version 2.0). Genomic amplification of the extracted viral RNA was carried out using the OneStep RT-PCR FluA+FluB automated system with the SmartCycler amplification system. Each sample was inoculated into 2 SV of the MDCK cell line. Turnaround times were calculated from the time specimens were received in the laboratory to the time the result was reported to clinicians. RESULTS: The EIA system detected 27 (21.6%) positive samples, RT-PCR 62 (49.6%) positive samples, and SV 56 (44.8%) positive samples. Among the 62 positive samples, EIA detected 27 (43.5%), RT-PCR 62 (100%) and SV 56 (90.3%). With the use of RT-PCR, 38.4% of the adults studied were diagnosed on the same day samples were received. Among the total, 67.2% of diagnostic results were obtained within the first 24 hours; turnaround time was 1.1 days. CONCLUSION: The real-time RT-PCR method studied displayed high sensitivity and specificity in the detection of influenza virus in adult patients, when compared with the conventional techniques. With real-time RT-PCR, large numbers of samples can be rapidly tested and results provided the same day samples are received.

Multiplicidad diagnóstica en los trastornos de la personalidad / Diagnostic multiplicity in personality disorders

Introducción: La multiplicidad diagnóstica es un fenómeno ligado a la comorbilidad que se estudia en relación con la articulación entre los ejes I y II del DSM-IV-TR. Las investigaciones señalan que en los pacientes con trastorno límite tener múltiples diagnósticos en el eje I es más probable que en otros pacientes. El objetivo del estudio es examinar el fenómeno de la multiplicidad diagnóstica. Pacientes y método: Se compara el número de diagnósticos al alta de 435 pacientes, divididos en 3 grupos: 94 con trastorno límite de la personalidad, 124 con otros trastornos de la personalidad y 220 con esquizofrenia, trastorno esquizofreniforme o trastorno esquizoafectivo. Resultados: El 87,1% de los pacientes con trastorno límite y el 88,6% de los pacientes con otros trastornos de la personalidad recibieron más de un diagnóstico, a diferencia del 35,2% de los pacientes con diagnóstico "esquizo". Los trastornos de la personalidad tuvieron 13,48 (intervalo de confianza [IC] del 95%, 8,2-22,1) veces más riesgo de recibir 2 o más diagnósticos que los pacientes con diagnóstico "esquizo". Los trastornos de la personalidad tuvieron 27,7 y 9,6 veces más riesgo de recibir, respectivamente, los diagnósticos de trastorno del estado de ánimo (IC del 95%, 8,5-89,9) y trastorno mental no especificado (IC del 95%, 4,9-18,8) que los pacientes con diagnóstico "esquizo". Conclusiones: La multiplicidad diagnóstica es un fenómeno iatrogénico ligado a todos los trastornos de la personalidad y es un signo evidente de la dificultad para clasificar a estos pacientes

Introduction: Diagnostic multiciplicity is related to comorbidity. This phenomenon has been studied in relation to the connection between axes I and II of the DSM-IV-TR. Research suggests that patients with borderline personality disorder (BPD) are more likely to have multiple axis I diagnoses than other patients. Patients and method: The aim of this study was to examine the phenomenon of diagnostic multiplicity by comparing the number of discharge diagnoses in 435 patients divided into three groups: 94 with BPD, 124 with other personality disorders and 220 with schizophrenia, schizophreniform or schizoaffective disorder. Results: A total of 87.1% of patients with BPD and 88.6% of those with other personality disorders received more than one diagnosis compared with 35.2% of patients with schizophrenia-related diagnoses. Patients with personality disorders had 13.48 times more risk of receiving two or more diagnoses (95% CI, 8.2-22.1), 27.7 times more risk of receiving a diagnosis of mood disorders (95% CI, 8.5-89.9) and 9.6 times more risk of receiving a diagnosis of non-specified mental disorders (95% CI, 4.9-18.8) than those with schizophrenia-related diagnoses. Conclusions: Diagnostic multiplicity is an iatrogenic phenomenon linked to all the personality disorders and is an obvious sign of the difficulty of classifying these patients