Factors associated with pneumococcal and influenza vaccination in hospitalized people aged ≥65 years.

Socioeconomic factors and the patterns of use of health services associated with influenza and pneumococcal vaccination were studied in people aged ⩾65 years admitted to three general hospitals in Spain between 2005 and 2007. The following data were collected: age, sex, risk of pneumonia, educational level, social class, type of household, physician visits, length of time with the same general practitioner, and influenza and pneumococcal vaccination (23vPPV). Associations between variables were assessed using multivariate logistic regression analysis. In total, 1702 patients were included; 59·9% had received 23vPPV and 65·6% influenza vaccine. Older age (OR 1·04, P<0·001), living with a partner (OR 1·72, P=0·003) and influenza vaccination during the last year (OR 6·64, P<0·001) were associated with 23vPPV. Male sex (OR 1·44, P=0·005), older age (OR 1·02, P=0·009), moderate risk of pneumonia (OR 1·58, P=0·001), living with a partner (OR 1·52, P=0·015) and frequent physician visits during the last year (1-6 annuals visits (OR 2·65, P<0·001); >6 visits (OR 3·83, P<0·001)) were associated with influenza vaccination. Coordination between public health and primary-care services may be necessary to improve vaccine uptake.

Effectiveness of the pneumococcal polysaccharide vaccine in preventing pneumonia in the elderly.

The objective of our study was to evaluate the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV) in preventing hospital admission for community-acquired pneumonia (CAP) in people ≥65 yrs of age. We conducted a matched case-control study in patients with CAP admitted to five Spanish hospitals. Cases were persons aged ≥65 yrs admitted to hospital through the emergency department, who presented a clinical and radiological pattern compatible with pneumonia, assessed using established criteria. We matched each case with three control subjects by sex, age (±5 yrs), date of hospitalisation (±30 days) and underlying disease. The study period was May 1, 2005 to January 31, 2007. The PPV immunisation status of cases and controls was investigated. Adjusted ORs for vaccination were calculated using logistic regression analysis. A total of 489 cases and 1,467 controls were included in the final analysis. The overall adjusted vaccination effectiveness for all patients was 23.6% (95% CI 0.9-41.0). The adjusted vaccination effectiveness for immunosuppressed patients was 21.0% (95% CI -18.7-47.5). Our results suggest that the PPV may potentially reduce hospitalisations for pneumonia in the elderly and supports vaccination programmes in this age group.

Effects of highly active antiretroviral therapy on vaccine-induced humoral immunity in HIV-infected adults.

OBJECTIVES: The acquisition of adequate vaccine-induced humoral immunity is especially important in HIV-infected individuals, who are at increased risk of infections. The aim of the study was to assess the safety of administering a complete vaccination programme to successfully treated HIV-infected adults and to evaluate specific humoral responses and the effect of highly active antiretroviral therapy (HAART) interruption on these responses. METHODS: A placebo-controlled, double-blind clinical trial was designed and 26 HIV-infected adults enrolled. Study participants were randomized to receive either a complete immunization schedule with commercial vaccines or placebo for 12 months. HAART was then discontinued for 6 months. Specific humoral responses were evaluated at baseline, at month 12 and after HAART interruption and compared between groups. RESULTS: There were neither local nor systemic secondary effects related to vaccination. Specific humoral responses to vaccines were adequate, but a loss of immunoglobulin G titres was observed after HAART interruption in 12 study participants. CONCLUSIONS: HAART interruption may cause impairment of previously acquired vaccine-induced immunity in HIV-infected adults.

A new adjuvant improves the immune response to hepatitis B vaccine in hemodialysis patients.

Prehemodialysis and hemodialysis patients are at an increased risk of hepatitis B infection and have an impaired immune response to hepatitis B vaccines. We evaluated the immune response to the new adjuvant of hepatitis B vaccine AS04 (HBV-AS04) in this population. We measured antibody persistence for up to 42 months, and the anamnestic response and safety of booster doses in patients who were no longer seroprotected. The primary vaccination study showed that HBV-AS04 elicited an earlier antibody response and higher antibody titers than four double doses of standard hepatitis B vaccine. Seroprotection rates were significantly higher in HBV-AS04 recipients throughout the study. The decline in seroprotection over time was significantly less in the HBV-AS04 group with significantly fewer primed patients requiring a booster dose over the follow-up period. Solicited/unsolicited adverse events were rare following booster administration. Fifty-seven patients experienced a serious adverse event during the follow-up; none of which was vaccine related. When HBV-AS04 was used as the priming immunogen, the need for a booster dose occurred at a longer time compared to double doses of standard hepatitis B vaccine. Hence, in this population, the HBV-AS04 was immunogenic, safe, and well-tolerated both as a booster dose after HBV-AS04 or standard hepatitis B vaccine priming.

Serological survey of hepatitis B immunity in healthcare workers in Catalonia (Spain).

Healthcare workers (HCW) are exposed to preventable infectious diseases, notably hepatitis B (HB). The aim of this study was to determine the immunity of HCW against hepatitis B. We made a seroprevalence study using a self-administered survey and obtained blood samples. Antibodies against the HB surface antigen (anti-HBs) and against the HB core antigen (anti-HBc) were studied. The odds ratio (OR) and 95% confidence intervals (CI) were calculated. The adjusted OR were calculated using logistic regression. Of the 644 HCW who participated (29.7% physicians, 38.7% nurses, 13.4% other clinical workers and 18.3% non-clinical workers), 46.4% were primary care workers and 53.6% hospital workers. The overall prevalence of anti-HBs was 64.4%. HCW aged <25 y had a significantly higher prevalence (86.7%) than those aged 35-44 y (adjusted OR 3.40; 95% CI 1.06-10.90). The prevalence of anti-HBc was 4.1%, and increased with age. Significant differences were found for HCW aged >44 y with respect to those aged 25-34 y. 75.6% of HCW stated they were vaccinated, but only 39.3% had a vaccination card. In HCW who stated they were unvaccinated, 10.8% had a vaccinated serological pattern (anti-HBc-negative and anti-HBs -positive). Written, updated vaccination records are essential to reliably determine the vaccination status.

Hepatitis B and A vaccination in HIV-infected adults: A review.

Hepatitis B and A account for considerable morbidity and mortality worldwide. Immunization is the most effective means of preventing hepatitis B and A. However, the immune response to both hepatitis vaccines seems to be reduced in HIV-infected subjects. The aim of this review was to analyze the immunogenicity, safety, long-term protection and current recommendations of hepatitis B and A vaccination among HIV-infected adults. The factors most frequently associated with a deficient level of anti-HBs or IgG anti-HAV after vaccination are those related to immunosuppression (CD4 level and HIV RNA viral load) and to the frequency of administration and/or the amount of antigenic load per dose. The duration of the response to both HBV and HAV vaccines is associated with suppression of the viral load at vaccination and, in the case of HBV vaccination, with a higher level of antibodies after vaccination. In terms of safety, there is no evidence of more, or different, adverse effects compared with HIV-free individuals. Despite literature-based advice on the administration of alternative schedules, revaccination after the failure of primary vaccination, and the need for periodic re-evaluation of antibody levels, few firm recommendations are found in the leading guidelines.

Seroepidemiology of HIV-1 infection in a Catalonian penitentiary.

A seroepidemiological study of HIV-1 infection was carried out among all the subjects who were imprisoned in a correctional centre in Catalonia (Spain) between October 1987 and April 1988. Six hundred and thirty-one inmates (male, mean age 19.1 +/- 1.7 years) were surveyed. The overall prevalence of HIV-1 infection was 33.6%. Statistically significant differences were observed between intravenous drug users (IVDUs) and non-IVDUs (P less than 0.0000001) and between regular and irregular IVDUs (P less than 0.000001). The age at which the person started using drugs and the length of time spent in prison were also significantly associated with the prevalence of infection. No other variables, except the higher prevalence among the gipsy ethnic group, showed any statistically significant association with HIV-1 infection.

Prevention and control of nosocomial infections in Spain: current problems and future trends.

Spain is a state member of the European Union, with more than 180,000 hospital beds and 800 public and private institutions. Only 6.9% of our gross national product is devoted to health expenditures. All citizens receive free health care through the National Health System. This system has given increasing attention to the prevention and control of nosocomial infections since 1986. In this article, results of serial prevalence surveys of antibiotic use and resistance patterns of microorganisms isolated from nosocomial infections are discussed. The needs for future development of infection control and quality assurance training programs in Spain also are discussed. Overall, a clinically and epidemiologically oriented approach to infection control is preferred, with greater emphasis in the role of infection control practitioners and infection control committees.

Handwashing with soap or alcoholic solutions? A randomized clinical trial of its effectiveness.

BACKGROUND: The effectiveness of an alcoholic solution compared with the standard hygienic handwashing procedure during regular work in clinical wards and intensive care units of a large public university hospital in Barcelona was assessed. METHODS: A prospective, randomized clinical trial with crossover design, paired data, and blind evaluation was done. Eligible health care workers (HCWs) included permanent and temporary HCWs of wards and intensive care units. From each category, a random sample of persons was selected. HCWs were randomly assigned to regular handwashing (liquid soap and water) or handwashing with the alcoholic solution by using a crossover design. The number of colony-forming units on agar plates from hands printing in 3 different samples was counted. RESULTS: A total of 47 HCWs were included. The average reduction in the number of colony-forming units from samples before handwashing to samples after handwashing was 49.6% for soap and water and 88.2% for the alcoholic solution. When both methods were compared, the average number of colony-forming units recovered after the procedure showed a statistically significant difference in favor of the alcoholic solution (P <.001). The alcoholic solution was well tolerated by HCWs. Overall acceptance rate was classified as "good" by 72% of HCWs after 2 weeks use. Of all HCWs included, 9.3% stated that the use of the alcoholic solution worsened minor pre-existing skin conditions. CONCLUSIONS: Although the regular use of hygienic soap and water handwashing procedures is the gold standard, the use of alcoholic solutions is effective and safe and deserves more attention, especially in situations in which the handwashing compliance rate is hampered by architectural problems (lack of sinks) or nursing work overload.

Reactogenicity profile of tetanus-diphtheria (adult-type) vaccine: results of a naturalistic study performed at an adult vaccination center.

A prospective observational naturalistic study was conducted at a vaccination center to assess the reactogenicity of tetanus-diphtheria (adult-type) (Td) vaccine. In 1 year, 3072 adult subjects were invited to participate, of whom 1977 (62% women, mean age [+/- SD]: 39 [+/- 14.5] years [range: 18-85 years]) actively did so. A follow-up diary card was provided to all subjects to record all local and general symptoms experienced during the following 4 days after vaccination. Of the study population (n = 1977), 280 received a second Td dose, and 30 received a third dose: the total number of diary cards collected was 2287. Td was always administered (i.m. route) in the left arm. The study population was grouped by age: 52%, 41%, and 7% were ages 18 to 35, 36 to 65, and > 65 years, respectively, most of them being travelers to developing countries. Close to two-thirds of subjects received up to nine different vaccines (mainly hepatitis B, hepatitis A, and typhoid) in addition to Td. Adverse reactions were classified as mild, moderate, and severe. Overall, 50% of subjects reported some type of adverse reaction. Pain, discomfort with arm movement, swelling, malaise, and fever (axillary temperature > or = 38 degrees C) were recorded in 43%, 14%, 3.8%, 5.1%, and 1.7% of all diary cards, respectively. Local and general reactions were considered as mild by almost two-thirds of vaccinees and lasted < or = 48 hours in about three-fourths of them. The incidence of moderate plus severe local reactions was significantly (p < 0.01) more commonly reported in the 18- to 35-year-old group than in the 36- to 65-year-old group. No statistically significant differences were observed when comparing the incidence of general adverse reactions of those receiving Td alone with those receiving additional vaccines or when comparing the duration and intensity by age groups. Only 5.2% of subjects required analgesic/antipyretic treatment. In conclusion, this study shows that Td vaccine is reasonably well tolerated when given alone or with other vaccines. Similar studies should be conducted with other vaccines routinely recommended to adults to assess how they are administered in usual clinical practice and the reactogenicity profile perceived by the vaccinees.

[Efficiency of prevaccination screening of anti-HBc in the anti-hepatitis B vaccination programs]. / Eficiencia de la detección prevacunal de anti-HBc en los programas de vacunación antihepatitis B.

BACKGROUND: The convenience of carrying out pre-vaccination screening of VHB markers depends on the relative costs of screening and vaccination and also on the prevalence of susceptible subjects in each group of the population. The aim of the present work was to analyse the efficiency of pre-vaccination screening of antiHBc in Catalonia in 1991. METHODS: The per-unit cost of screening was calculated at 1366 ptas. The formula applied was: cost per-unit of screening + (1-X) x the cost per-unit of vaccination of anti-HBc (-) = cost of vaccinating the group. "X" being the threshold of prevalence of markers below which screening cases to be efficient. This prevalence is compared with those expected in the groups of the population to be vaccinated. RESULTS: By applying the above-mention ned formula and taking into account costs in time and travel of the people to be vaccinated, a prevalence threshold of 23% is obtained. This prevalence is much higher than that found in adolescents and students of medicine and nursing, similar to that found in health professionals and lower than that of other risk groups. CONCLUSIONS: Systematic screening of anti-HBc is only recommended in groups of the population where a prevalence higher than 20-25% can be expected. Below this threshold vaccination without previous study of markers is more efficient. This enormously simplifies the strategies of universal vaccination of children, adolescents or both.

[Risk of nosocomial infection in elderly patients admitted to a university hospital]. / Riesgo de infección nosocomial de los pacientes ancianos ingresados en un hospital universitario.

BACKGROUND: A high percentage of current hospital visits are made by the elderly. The aim of this work is to quantify the risk of contracting a nosocomial infection among elderly patients admitted to a university hospital. METHODS: From the patients admitted from the emergency unit, outpatients and the waiting list, 6 patients of different age groups were chosen each day by a simple random sampling. The criteria of nosocomial infection were those of the CDC. The analysis of the information was made with the programme EPIINFO version 5. The chi 2 tests and Fisher's exact test were used to compare proportions. RESULTS: The rate of nosocomial infection in the group aged over 64 was 14.8%, showing statistically significant differences with respect to other age groups (p = 0.001). In this group the predominant infection was urinary, with an odds-ratio of 3.69, in comparison with the 25 to 44 age group. A prolonged hospital stay (> 15 days) has proved to be closely related to the risk of nosocomial infection in all age groups (p < 0.0001) in patients over 64. CONCLUSIONS: The greater risk of contracting nosocomial infections in the elderly makes it advisable to develop specific prevention programmes for this group, and the fitness of accommodations the length of stay to the care needs suitable to the hospital level.

[The efficacy of the prevaccination detection of anti-HAV in hepatitis A vaccination programs]. / Eficiencia de la detección prevacunal de anti-VHA en los programas de vacunación antihepatitis A.

BACKGROUND: The convenience of carrying out prevaccination detection studies of hepatitis A virus (HAV) markers depends on the relative costs of the detection and vaccination, as well as the prevalence of susceptible subjects in each population group to be vaccinated. The aim of this study was to analyze the efficacy of the systematic prevaccination detection of anti-HAV antibodies in Catalonia, Spain. METHODS: The following formula was applied: Unit cost of detection + (1-X) x Unit cost of vaccination of anti-HAV negative subjects = group vaccination cost, with X being the threshold of prevalence of marker under which detection no longer remains efficient. This prevalence was compared with the findings of a seroepidemiologic survey carried out in international travellers and food handlers. RESULTS: The unit cost of the detection of anti-HAV was calculated as 2,733 pesetas, and the unit cost of the vaccination as 9,963 pesetas obtaining a prevalence anti-HAV threshold of 27%. This prevalence corresponds to travellers under the age of 30 years and food handlers under the age of 25 years. CONCLUSIONS: The systematic detection of anti-HAV is only recommended in population groups in which prevalences higher than 27% may be expected. The vaccination is more efficient without a previous marker study under this threshold. According to this study, direct vaccination of food handlers under the age of 25 years (born after 1969) is recommended as is that of international travellers under the age of 30 years (born after 1964). In those over the age of these collectives, the prevaccination study is more efficient.

[Impact of hospital admissions for pneumonia in a tertiary Spanish hospital]. / Impacto sanitario de los ingresos por neumonía en un hospital de tercer nivel.

BACKGROUND: Impact of hospital admissions for pneumonia during 1998 in the Hospital Clínic, Barcelona. PATIENTS AND METHOD: Retrospective information on the hospitalizations for pneumonia was collected. RESULTS: During 1998 a total of 626 adult were admitted with a hospital diagnosis of pneumonia (72% were >/= 65 years). The average length of stay was 10 days. Half of these patients were previously hospitalized during the preceding 5 years. CONCLUSIONS: Hospital admissions due to pneumonia (17 cases per 1.000 hospitalizations) accounted for an estimated cost of 2.3% of the cost of all the hospitalized patients.

[Infection by the human immunodeficiency virus type 1 in the population of prisoners of Catalonia]. / Infección por el virus de la inmunodeficiencia humana tipo 1 en la población penitenciaria de Cataluña.

BACKGROUND: The prison population represents a high risk group for the human immunodeficiency virus type 1 infection. The present study was carried out to know the prevalence of infection in this collective in three penitentiary centers in Catalonia. METHODS: All the subjects who were in or who were admitted to the three penitentiaries for men from October 1987 to April 1988 were included in the study (n = 1,579). Demographic risk factor and penitentiary variables were obtained. The determination of anti-HIV-1 antibodies was performed by enzymoimmunoanalysis (Dupont HIV ELISA). RESULTS: The global prevalence of HIV-1 infection was of 40.6%. Significant statistical differences were found among intravenous drug users (IVDU) and non IVDU (chi 2 = 376.8, p < 0.0001, OR = 9.6, CI 95% = 7.5 - 12.3) and between habitual and sporadic users (chi 2 = 23.9, p < 0.0001, OR = 3.0, CI 95% = 1.9 x 4.7). CONCLUSIONS: The penitentiary population in Catalonia is a collective with a high prevalence of infection by the human immunodeficiency virus type 1, with intravenous drug use being the fundamental factor associated to this prevalence.

[Excess length of stay attributable to nosocomial bacteremia: usefulness of the Hospitalization Appropriateness Protocol]. / Prolongación de la estancia atribuible a la bacteriemia nosocomial: utilidad del Protocolo de Adecuación Hospitalaria.

BACKGROUND: To evaluate the usefulness of the Appropriateness Evaluation Protocol (AEP) for assessing the extra length of stay attributable to nosocomial bacteremia. PATIENTS AND METHODS: Retrospective review of the medical records (1989, 1990 and 1991) of all patients, who developed Staphylococcus aureus nosocomial bacteremia. Evaluation of hospital stay was performed using the AEP. Calculation of the kappa index and intraclass correlation coefficient. RESULTS: A total of 158 patients were included S. aureus nosocomial bacteremia is responsible for a mean excess length of stay of 4.3 days per patient. Kappa index for the method used was 76%, and intraclass correlation coefficient was 61%. CONCLUSIONS: The AEP has been shown to be a reliable tool for assessing the extra days of stay attributable to nosocomial bacteremia in the Spanish National Health System. The use of AEP should be extended to assess the extra stay attributable to other types of nosocomial infections.

[Hepatitis B and hepatitis delta in young inmates]. / Hepatitis B y delta en reclusos jóvenes.

The prevalence of infection by hepatitis B (HBV) and delta (HDV) viruses and presumably related variables were evaluated in a prison for young male convicts, aged 16-21 years (n = 686), 55.1% of convicts were positive for one or more VHB markers, and 7.1% were positive for HBsAg; 89.7% of these were negative for IgM anti-HBc (chronic carriers), while 36.6% were positive for HBeAg. Anti-delta antibodies were detected in 37.5% of chronic carriers. The seropositivity of HVB markers was much higher in parenteral drug abusers (PDA) as compared with non PDA (76.3% vs 26.7%, p less than 0.0000001, OR = 8.82). Among PDA, it was higher in regular users than in occasional ones (83.3% vs 62.9%, p = 0.0001, OR = 2.95) and in those who had acquired the habit at an early age (p = 0.035). The stratified analysis also showed an association of VHB infection with other variables, basically ethical and prison-related. The possibility to develop active immunization programs is evaluated.

[The vaccination of medical and nursing students against hepatitis B]. / Vacunación de estudiantes de medicina y enfermería frente a la hepatitis B.

BACKGROUND: Vaccination against the hepatitis B virus (HBV) of health care staff during their studies would have the advantage of early prevention when the prevalence of infection is presumably low. METHODS: The population to be protected is made up of 1533 medical and nursing students. In those who accepted, anti-HBc was determined and information was obtained concerning circumstances of exposure to HBV. Vaccination was offered to all the cases of negative anti-HBc. Individuals receiving 3 doses of the vaccination (20 micrograms at 0, 1 and 6 months) were seen at 4-7 months of the last dose to determine the anti-HBs titers achieved. RESULTS: One thousand sixty-five students (70%) accepted inclusion into the prevaccination anti-HBc study and 1,029 (3.4%) were anti-HBc negative. Only older age and previous transfusions and jaundice were significantly associated to greater prevalence of infection by HBV. The adherence to 1, 2 or 3 doses of the vaccination was 96%, 94% and 87%, respectively. Following the 3 doses, > or = 10 UI/I of anti-HBs were detected in 97% of the cases studied with geometric measurement of the responders being 1580 U/I. The titer had an inverse relation which was not significant with age. CONCLUSIONS: The high participation in the program of anti-hepatitis B vaccination and the excellent immune response observed leads to the recommendation of systemic vaccination to future health care professionals during their study period. Furthermore, the low prevalence of previous HBV infection advises against previous detection of anti-HBc with immunization of the whole collective being more effective.

[Prevalence of hepatitis B and hepatitis A virus infection among health sciences students in Catalonia, Spain]. / Prevalencia de infección por virus de la hepatitis B y hepatitis A en estudiantes de profesiones sanitarias en Cataluña.

BACKGROUND: To know current hepatitis B (HBV) and hepatitis A (HAV) infection status among a group of health sciences students during 1990-1993 period. SUBJECTS: 1,734 health sciences students during 1990-1991, 1992-1993 and 1993-1994 academic years. MAIN OUTCOME MEASURES: demographic variables, vaccination history against HAV and HBV viruses, anti-HBc and anti-HAV antibody titres (ELISA kits). RESULTS: 1,734 subjects aged 22.5 +/- 2.9 years (75% women) were included. Anti-HBc total cumulated prevalence during the three year period was 2.5% (CI 95%, 1.9%-3.4%). Anti-HAV total cumulated prevalence during the three year period was 13.9% (CI 95%: 11.4%-16.8%). No statistical significant association between antibody prevalence and both age sex was found. CONCLUSIONS: Low prevalence, and thus, high susceptibility to HBV and HAV infection was found. We stress the importance of systematic vaccination among health sciences students not previously engaged in universal vaccination programmes. We also point out the need for further analysis upon the utility of combined HB/HA vaccine as an alternative to antihepatitis B universal vaccination programmes among adolescent cohorts.

[Nosocomial infections due to opportunistic fungi: analysis of a news outbreak in the Spanish press]. / Infecciones nosocomiales por hongos oportunistas: análisis de una serie de noticias publicadas en la prensa española.

BACKGROUND: To study an outbreak of media news related to nosocomial infections due to opportunistic fungi in Spanish hospitals. CASE DEFINITION: any news related to possible nosocomial infection due to opportunistic fungi in Spanish hospitals, published in national or local daily newspapers, over the pre-epidemic (July-December, 1998) and epidemic periods (January-June, 1999). All news were reviewed and identified using global press reports summaries, prepared by two independent sources, and were analyzed by three different observers. RESULTS: Over the pre-epidemic period there were not any news related to nosocomial infections due to opportunistic fungi. Over the epidemic period, a total of 218 news were identified, 154 (71%) published in national newspapers and 64 (29%) in local ones. We analyzed separately 18 editorials or opinion articles related to this subject. The epidemic curve (distribution of news by week) showed an incidence news peak at week 5 (102 news, 46.7% of all news published). The media mentioned up to 19 different hospitals as institutions with possible cases of nosocomial fungal infections. After week 8, news incidence drop, and remain thereafter at minimum levels. CONCLUSIONS: The example provided by the analysis of this outbreak of media news, related to nosocomial infections by Aspergillus an other opportunistic fungi, is useful to allow us understand how some medical news arise, develop and were transmitted. The public alert situation created in Spain was remarkable, and it is likely that there was a transient loss of confidence in the safety of public health institutions. Today's medicine requires a great and better openness to the media, and a better cooperation between both parts.