Declining hepatitis A seroprevalence in adults in Catalonia (Spain): a population-based study.

BACKGROUND: One of the main uses of seroprevalence studies it to evaluate vaccination programmes. In 1998, a programme of universal vaccination of preadolescents in schools with the hepatitis A vaccine was begun in Catalonia. The objective of this study was to investigate the prevalence and risk factors of hepatitis A virus infection (HAV) in a sample of the adult population of Catalonia in 2002 and to evaluate the changes with respect to a survey carried out in 1996. METHODS: The prevalence of HAV antibodies was determined by a third generation competitive immunometric assay in a representative sample of 1292 people aged >15 years. The association between the prevalence and different sociodemographic variables was determined by multiple logistic regression analysis. RESULTS: The standardized global prevalence of HAV antibodies in 2002 was 68.2%, increased with age (p < 0.0001) and was associated with being born outside Catalonia (OR: 1.75; 95% CI 1.11-2.76) and lower social class (OR: 1.14; 95% CI 1.05-1.25). Compared with the last survey carried out in 1996 the standardized global prevalence was lower (68.2% vs 77.8%; p < 0.0001) as was the prevalence in people under 45 years. CONCLUSION: The prevalence of the hepatitis A virus is decreasing in the adult population of Catalonia, especially in the younger age groups. The programme of vaccination of adolescents begun in 1998 to control the disease can provide indirect protection to the unvaccinated population.

Effectiveness of pneumococcal vaccination for elderly people in Catalonia, Spain: a case-control study.

BACKGROUND: Observational studies offer an approach to evaluating the effectiveness of vaccination programs. We evaluated the effectiveness of a 23-valent pneumococcal vaccination program for elderly people in Catalonia, Spain, in a matched-set case-control study. METHODS: We identified 149 cases of invasive pneumococcal disease among patients aged > or =65 years who were hospitalized in 12 large hospitals in Catalonia during the period of 1 January 2001 through 31 March 2002. We selected 2 hospital control patients and 1 outpatient control subject for each case patient, matching on the basis of age and underlying medical conditions. We obtained their pneumococcal vaccination histories and used conditional logistic regression to determine effectiveness of vaccination. RESULTS: Among all 149 cases of invasive pneumococcal disease, 131 (87.9%) were caused by vaccine or vaccine-related serotypes. In the adjusted analysis, overall effectiveness of vaccination against infections due to all serotypes was 70% (95% confidence interval [CI], 48%-82%). Among immunocompetent subjects with or without high-risk conditions, effectiveness of vaccination was 76% (95% CI, 51%-88%), but among immunocompromised subjects it was 50% (95% CI, -44% to 82%). Among subjects with infections due to vaccine or vaccine-related serotypes, effectiveness of vaccination was 72% (95% CI, 50%-85%) overall and 78% (95% CI, 50%-90%) in those who were immunocompetent, but it was only 46% (95% CI, -54% to 81%) in those who were immunocompromised. Overall effectiveness of vaccination was 65% (95% CI, 35%-81%) during the noninfluenza period. CONCLUSIONS: Pneumococcal vaccination was effective in preventing invasive pneumococcal disease among all elderly persons in Catalonia. Effectiveness was greater in immunocompetent persons, most of whom had underlying high-risk conditions. The number of subjects was too small to determine whether vaccination was effective in those who were immunocompromised.

Invasive disease caused by Haemophilus influenzae: the sensitivity of statutory reporting.

PURPOSE: The objective of the study was to investigate the sensitivity of the statutory reporting of Haemophilus influenzae invasive disease (HIID) during the period between 1996 and 1997 in Catalonia, Spain. METHODS: The incidence of HIID reported passively by clinicians was compared with the cases detected by a system of microbiological surveillance. In all cases isolated, the age of the patient, the clinical form and the serotype were investigated. RESULTS: Sixty-six cases were passively reported and 111 were detected by microbiological surveillance. Overall sensitivity of reporting was 59.5% (95% CI, 50.7-69.1), with differences being observed according to the variables studied. The highest values were obtained in children under 5 years (87.8%; 95% CI, 73.7-95.9), in cases with meningitis and/or sepsis (64.3%; 95% CI, 50.4-76.6) and in serotype b (73.0%; 95% CI, 60.3-83.4). In the logistical regression analysis, only age under 5 years was associated with greater reporting (OR= 9.8; 95% CI, 2.5-37.8). CONCLUSIONS: Reported morbidity in children under 5 years is a good estimate of the true incidence of HIID in Catalonia (underreporting was 12.2%), but not for those above this age in whom the underreporting was 57.2%.

[Outbreak of gastroenteritis caused by Campylobacter jejuni transmitted through drinking water]. / Brote comunitario de gastroenteritis por Campylobacter jejuni originado por el consumo de agua del suministro público.

BACKGROUND: The aim of this study was to conduct a clinical-epidemiological and microbiological investigation into an outbreak of waterborne disease caused by Campylobacter jejuni due to the consumption of drinking water. PATIENTS AND METHOD: A historical cohort study was carried out among 237 residents of Torres de Segre (Lleida, Spain) who were selected using a systematic sample. We conducted a telephone interview about water consumption, symptoms and the onset of disease. We investigated samples of drinking water and stools from 14 patients. The risk associated with each water source was assessed by applying relative risk (RR) analysis at 95% confidence (CI) intervals. RESULTS: The overall attack rate was 18.3% (43/237). The symptoms were: diarrhoea, 93.0% (18/43); abdominal pain, 80.9% (34/42); nausea; 56,1% (23/41); vomits, 42.9% (18/42), and fever, 11.9% (5/42). Only 5.8% of patients contact with his physician. The consumption of drinking water was statistically associated with the disease (RR = 3.0; 95% CI, 1.7-5.3), while the consumption of bottled water (RR = 0.6; 95% CI 0.3-1.0) and water from other villages (RR = 0.3; 95% CI, 0.1-1.1) were a protection factor. The day of outbreak notification we did not detect any residual chlorine in the drinking water: it was qualified as no potable and we isolated Campylobacter jejuni in 8 samples stools. CONCLUSIONS: This research highlights the potential importance of waterborne outbreaks of gastroenteritis due to Campylobacter jejuni transmitted through untreated drinking water and suggests to need systematic controls over drinking water and the proper register of their results.

[Outbreak of foodborne disease by Norwalk-like viruses genogroup II]. / Toxiinfección alimentaria por virus Norwalk-like genogrupo II.

BACKGROUND: Our goal was to investigate the epidemiological characteristics and etiology of an outbreak of food-borne disease caused by Norwalk-like viruses, genogroup II. PATIENTS AND METHOD: We performed a historical cohort study on the consumption of 21 food items and clinical symptoms. We assessed RNA Norwalk-like viruses by RT- PCR in stool samples from 5 patients and 2 food-handlers. The potential involvement of each food item was assessed by relative risk at 95% confidence intervals (CI). RESULTS: The overall attack rate was 70.0% (7/10). The median incubation period was 35.0 hours. Symptoms included: vomits 85.7% (6/7), fever 85.7% (6/7) and diarrhoea 71.4% (5/7). Four food items were involved [fish (RR = 1.7; CI 95% 0.9-3.3); 'selection of cold meats' (RR = 1.6; CI 95% 0.9-2.7); yoghurt (RR = 1.5; CI 95% 1.0-2.4) and lamb (RR = 1.3; CI 95% 0.6-3.0)]. Three stool sample gave positive results for Norwalk-like viruses genogroup II. Important oversights in food-handlers' work were detected. CONCLUSIONS: RT-PCR enabled us to confirm the etiology of this outbreak as Norwalk-like viruses genogroup II. Although patients recovered quickly, the outbreak caused considerable public alarm.

[Smoking prevalence in Catalonia (Spain), 1982-1998: a gender perspective]. / Prevalencia del tabaquismo en Cataluña, 1982-1998: una perspectiva de género.

BACKGROUND: We aimed at describing the smoking prevalence trend among the Catalan population (Spain) from 1982 to 1998, based on a gender perspective analysis. SUBJECTS AND METHOD: Data obtained from the surveys carried out by the Catalan Department of Health in 1982, 1986, 1990, 1994 and 1998 were analysed. Variables included were those related to smoking status, number of daily cigarettes, age and sex of the interviewed, type of tobacco smoked, age at which the first experience with smoking took place and smoking duration. Results are presented as proportions with 95% confidence interval and means with standard deviation. RESULTS: Global smoking prevalence in the 15 to 64 year-old population has remained stable between 1982 and 1998 (percentual variability: 1.1%). In 1998, there were 37.5% smokers. In women, the prevalence rate increased by 53.5% during the same period, reaching an overall prevalence of 30.7% in 1998. Among males, there was a 23.8% reduction, reaching an overall prevalence of 44.4%. The decreasing smoking prevalence trend observed among 15 to 24 year-old males and females until 1994 breaks between 1994 and 1998 so that the prevalence in young people increases in this period. In 1998, 26.1% women smoke light tobacco versus 10.4% males; women smoke an average 13.8 (8.8) daily cigarettes versus 19.7 (12.6) in males; mean smoking duration among women is 13.9 (10.1) years, while it is 22.6 (16.0) years among males. CONCLUSIONS: Despite the important reduction of smoking prevalence observed among males, the smoking prevalence rate of the Catalan population remains high. The situation is particularly unfavourable in young people of both sexes and in women, whose smoking habit has specific characteristics.

Cost-effectiveness of rifampin for 4 months and isoniazid for 6 months in the treatment of tuberculosis infection.

OBJECTIVES: To assess the cost-effectiveness ratio of rifampin for 4 months and isoniazid for 6 months in contacts with latent tuberculosis infection. METHODS: The cost was the sum of the cost of treatment with isoniazid for 6 months or with rifampin for 4 months of all contacts plus the cost of treatment of cases of tuberculosis not avoided. The effectiveness was the number of cases of tuberculosis avoided with isoniazid for 6 months or with rifampin for 4 months. When the cost with one schedule was found to be cheaper than the other and a greater number of tuberculosis cases were avoided, this schedule was considered dominant. The efficacy adopted was 90% for rifampin for 4 months and 69% for isoniazid for 6 months. A sensitivity analysis was made for efficacies of rifampin for 4 months of 80%, 69%, 60% and 50%. RESULTS: Of the 1002 patients studied, 863 were treated with isoniazid for 6 months and 139 with rifampin for 4 months The cost-effectiveness ratio with isoniazid for 6 month was € 19759.48/avoided case of tuberculosis and € 8736.86/avoided case of tuberculosis with rifampin for 4 months. Rifampin for 4 months was dominant. In the sensitivity analysis, rifampin for 4 months was dominant for efficacies from 60%. CONCLUSIONS: Rifampin for 4 months was more cost-effective than isoniazid for 6 months.

[Assessing the effectiveness of vaccination programs]. / Evaluación de la efectividad de los programas de vacunación.

Vaccines have contributed enormously to reducing the incidence of many communicable diseases. The protective efficacy of a vaccine refers to the health effects of the vaccine applied in optimal, ideal conditions, whereas the effectiveness of a vaccination program refers to the health effects of vaccination in the vaccinated individuals in clinical practice or within public health programs, which may differ widely from optimal conditions. Vaccine efficacy is estimated by randomized clinical trials. In contrast, effectiveness can be measured by various types of epidemiological studies: randomized community trials, in which the target vaccine is randomly assigned to a group and disease incidence in this group is compared with that of an unvaccinated group; cohort studies, which are observational epidemiological studies in which the vaccination status is known in healthy vaccinated (vaccinated cohort) and unvaccinated (unvaccinated cohort) people and the occurrence of the disease in the two groups is studied; and observational case-control studies, in which two groups are selected; one with the disease under investigation (cases) and the other without (controls), and vaccination histories are investigated in the two groups. Vaccine effectiveness may also be estimated by comparing attack rates in epidemic outbreaks or secondary attack rates in the home, or by screening.

Influence of prior pneumococcal and influenza vaccination on outcomes of older adults with community-acquired pneumonia.

OBJECTIVES: To determine whether prior pneumococcal and seasonal influenza vaccination improves outcomes in older adults hospitalized for community-acquired pneumonia (CAP). DESIGN: Prospective, observational, multicenter study. SETTING: Five public hospitals providing universal free care to the whole population in three Spanish regions. PARTICIPANTS: Individuals aged 65 and older admitted to the hospital with CAP through the emergency department. MEASUREMENTS: Pneumococcal and influenza vaccination status. The primary study outcomes were intensive care unit (ICU) admission, length of hospital stay (LOS), and overall case-fatality rate. Outcome variables of individuals vaccinated with both vaccines were compared with outcomes of those who were unvaccinated. RESULTS: Two hundred thirty-eight individuals had received 23-valent pneumococcal polysaccharide vaccine and seasonal influenza vaccination and were compared with 195 unvaccinated individuals. No differences were found with respect to combined antibiotic therapy between groups (38.0% vs 39.7%; P = .80). Similar percentages of vaccinated and unvaccinated individuals required ICU admission (7.2% vs 8.2%; P = .69). Mean LOS was significantly shorter in vaccinated individuals (9.9 vs 12.4 days; P = .04). Overall case-fatality rates were similar in both groups (5.9% vs 5.1%; P = .73). After adjustment, LOS, risk of ICU admission, and overall case-fatality rate were not associated with prior pneumococcal and seasonal influenza vaccination. CONCLUSION: The clinical outcomes of vaccinated older adults hospitalized with CAP were not better than those observed in unvaccinated individuals.

[Impact of 7-valent pneumococcal conjugate vaccination in a population with low to intermediate vaccination levels]. / Impacto de la vacuna neumocócica conjugada heptavalente en una población con valores bajos-intermedios de vacunación.

OBJECTIVE: To analyze the changes occurring in declared cases (microbiological report) of invasive pneumococcal disease (IPD) in children <2 years old in Catalonia (Spain) after the 7-valent pneumococcal conjugate vaccine (PCV7) was licensed for use. MATERIAL AND METHODS: Cases of IPD in children <2 years old were obtained from notifications to the Microbiological Reporting System of Catalonia (MRSC) in 1997-1999 and 2002-2004 by the hospitals (n=23) that have participated in the MRSC continuously and uninterruptedly since its inception in 1995. RESULTS: Overall reported rates were 49.2 cases per 100,000 persons-year in 1997-1999 and 40.4 per 100,000 persons-year in 2002-2004; the difference was not statistically significant. The rate of bacteremic pneumonia fell from 25.2 per 100,000 persons-year in 1997-1999 to 21.6 per 100,000 persons-year in 2002-2004, and meningitis from 6.0 to 4.3 per 100,000 persons-year; again, differences were not statistically significant (P>0.05). CONCLUSIONS: After PCV7 was licensed for use, a noticeable, but non-significant, reduction in reported IPD rates in children <2 years old occurred in Catalonia. If the results had been statistically significant, the overall reduction would have been 17.90%, not far below the theoretically expected reduction (22%), based on the protective efficacy of PCV7 (89%), the percentage of invasive disease-causing serotypes included in the vaccine (70%), and the vaccination coverage achieved during the study period (35%).

Seroepidemiology of hepatitis B virus infection in pregnant women in Catalonia (Spain).

BACKGROUND: In recent years there has been a substantial reduction in hepatitis B incidence as a result of routine vaccination of preadolescents and the selective vaccination of high risk groups and newborns of HBsAg+ mothers. OBJECTIVES: To determine the prevalence of hepatitis B virus infection markers and of serologic markers of hepatitis B vaccination in a representative sample of pregnant women in Catalonia. STUDY DESIGN: A representative sample was obtained by random cluster sampling (hospitals with maternity units) stratified by provinces. Anti-HBc, anti-HBs and HBsAg were determined using an ELISA test (Behring, Marburg, Germany). The crude and adjusted odds ratios for the sociodemographic variables analyzed were also calculated. RESULTS: The global prevalence of carriers of HBsAg+ was 0.1% (95% CI 0.0-0.3), that of hepatitis B infection (anti-HBc+) was 5% (95% CI 3.9-6.1) and that of serologic markers of vaccination (anti-HBs+ and anti-HBc-) was 16.4% (95% CI 14.5-18.2) The prevalence of infection increased with age from 3.0% (15-19 years age group) to 14.8% (40-44 years age group). The prevalence of anti-HBc+ was higher in women born in Asia (27.6%) and Africa (18.8%) than in those born in Spain (3.7%), Europe (3.3%) and America (4.6%), with the differences being statistically significant. CONCLUSIONS: The results of this study confirm the change in the pattern of endemicity of hepatitis B infection in pregnant women in Catalonia after the introduction of vaccination programmes. They also confirm the increasingly important role played by immigration in the epidemiology of hepatitis B.

Validity of self-reported pneumococcal vaccination status in the elderly in Spain.

The objective of this study was to evaluate the validity of information reported by the elderly on 23-valent pneumococcal polysaccharide vaccine (23vPPV) vaccination status. A cross-sectional, observational study was carried out in patients aged >or=65 years admitted to five Spanish hospitals. Data on 23vPPV vaccination history were obtained through interview of the patient or close relative and review of written medical information. The validity of the patient self-report was compared to the written medical information by calculation of the sensitivity, specificity, concordance, positive predictive value (PPV) and negative predictive value (NPV). A total of 2484 patients were initially included of whom 1814 patients (73%) responded about their vaccination status. The global sensitivity of the patient self-report was 0.74 and the specificity 0.95. The PPV was 0.92, the NPV 0.84 and the concordance 87. Vaccination cards and centralized vaccination registries in primary health care centres and hospitals should be potentiated in order to ensure that neither more nor less vaccinations are administered than are necessary.

Seroprevalence of varicella zoster virus infection in child and adult population of Catalonia (Spain).

The aim of this study was to determine the prevalence of varicella IgG antibodies in the population of Catalonia, and the variables associated. The study was carried out in 2002 in a representative sample of juvenile (5-14 years) and adult population (> or =15 years) of Catalonia (Spain). The global prevalence determined by ELISA test was 95.5% (95% CI 94.7-96.3). The prevalence increased with age, from 82% (95% CI 77.0-87.0) in the 5-9 years age up to 99.4% (95% CI 98.2-100) in >64 years of age. No statistically significant differences in the seroprevalence according to the sociodemographic variables were observed. The current strategy of vaccinating preadolescents at 12 years of age who have not suffered the disease will require more than 30 years to cover the current gap immunity in adolescents and young adults. Vaccination with two doses of vaccine for all adolescents and adults < or = 50 years who report not having suffered the disease during childhood should be considered.

Trends in dietary habits and food consumption in Catalonia, Spain (1992-2003).

OBJECTIVE: To analyse trends in food habits and food consumption from 1992 to 2003. DESIGN: Two consecutive cross-sectional nutrition surveys were carried out on random samples of the Catalan population (Evaluation of Nutritional Status in Catalonia (ENCAT) 1992-93 and ENCAT 2002-03). Dietary intake was assessed by means of two 24-hour recalls on non-consecutive days and a food frequency questionnaire was used to ascertain tendencies in the frequency of food consumption. SETTING: Catalonia region, Northeastern Spain. SUBJECTS: Analysis is based on a total of 4701 individuals: 2641 from ENCAT 1992-93 (1210 men and 1431 women) and 2060 from ENCAT 2002-03 (954 men and 1106 women), aged 10-75 years. RESULTS: The trends from 1992 to 2003 showed an increase in eating between meals and outside the home. There was also an upsurge in consumers for fast food, especially among young adults. Notable decreases in fruit consumption (from 301 to 224 g day(-1)) as well as in vegetables, potatoes, meat (red meat and chicken), fish (whitefish and seafood) and offals were observed. In contrast, there was an increase in dairy product consumption, in general (from 255 to 312 g day(-1)), as well as low fat and skim milk derivatives. Fruit juice, nuts and olive oil consumption also increased, the latter being consumed daily by 96% of the population. Little variation was observed for the rest of the food groups in the period studied. Overall, Catalonia is characterised by a model of consumption that is quite favourable, inherent to Mediterranean countries but with important differences according to age. CONCLUSION: Based on the food consumption trends observed in Catalonia, an increase in the consumption of fruits and vegetables, as well as whole grain cereals and fish, should be promoted, along with a reduction in the consumption of meat and sausages.

Rubella immune status of indigenous and immigrant pregnant women in Catalonia, Spain.

BACKGROUND: The objective of the study was to determine the prevalence of rubella antibodies in representative samples of pregnant women in Catalonia. METHODS: A representative sample of pregnant women in Catalonia was obtained by random sampling by clusters (hospitals with maternity units) stratified by provinces. Blood was obtained from the umbilical cord at childbirth in 1538 women (of whom 308 were immigrants) and was tested for rubella antibodies by ELISA (Enzime-linked immunosorbent assay). RESULTS: The global prevalence of antibodies was 93.4% [95% confidence interval (CI): 93.3-93.5] and was significantly higher in indigenous women (94.9;95%CI:93.3-95.9) compared with immigrants [89.0; 95%CI: 85.5-92.5 (P<0. 0001)] with crude Odds ratio (OR) of 2.15 (95%CI: 1.40-3.32).The prevalence was higher in women living in rural habitats (97%) and those in higher social classes (96.3%); OR 2.54 (95%CI: 1.22-5.30) and 2.17 (95%CI: 1.24-3.81), respectively. CONCLUSION: Fertile female immigrants from countries with no vaccination or where vaccination coverage is low should be actively approached for vaccination to reduce the risk of infection and congenital rubella.

Obesity and overweight trends in Catalonia, Spain (1992-2003): gender and socio-economic determinants.

OBJECTIVE: To evaluate the trends of overweight and obesity prevalences in the population of Catalonia, Spain, aged 18-75 years, and the influence of socio-economic determinants on these prevalence trends. DESIGN: Analysis based on data from two representative population-based cross-sectional surveys. SETTING: Data from the two Evaluations of Nutritional Status in Catalonia (ENCAT 1992-93 and ENCAT 2002-03), Spain. Weights and heights were obtained by direct measurement in standardised conditions by trained interviewers. Overweight and obesity were defined using body mass index (BMI) and waist circumference (WC), categorised according to WHO criteria. SUBJECTS: In total, 1015 men and 1233 women from ENCAT 1992-93, and 791 men and 924 women from ENCAT 2002-03. RESULTS: Mean BMI and mean WC were higher in males in 2002-03 as compared to 1992-93, while for females mean BMI was lower except for the youngest group, and mean WC was higher. In men, overall BMI overweight prevalence remained stable (from 44.1% to 43.7%), while obesity increased (from 9.9% to 16.6%); total WC overweight remained stable (from 21.7 to 23.8%), while WC obesity increased (from 13.1% to 24.4%). In women, overall BMI overweight increased (from 29.1% to 30.1%), whereas BMI obesity remained stable (from 15.0% to 15.2%); total WC overweight decreased (from 21.8% to 17.7%), while WC obesity increased (from 24.5% to 31.1%). The socio-economic and education variables had an influence on BMI and WC overweight and obesity rates mainly on females in both surveys and on the youngest men only in the 1992-93 survey. CONCLUSIONS: Ten-year trends indicate that Catalan males are getting bigger overall (BMI) and around the waistline (WC), while Catalan females only have bigger waistlines (WC). BMI male obesity prevalence has overtaken that of females. WC obesity continues to be more prevalent among females than males.

Trends in blood lipids and fat soluble vitamins in Catalonia, Spain (1992-2003).

OBJECTIVE: The purpose of this study was to assess the 10-year trend in lipid and antioxidant vitamin levels in the Catalan population from 1992 to 2003. DESIGN: Two cross-sectional surveys were carried out in Catalonia, Spain, during 1992-93 and 2002-03. A subsample of the individuals participating in the surveys agreed to undergo a biochemical evaluation. SUBJECTS: Eight hundred and eighty individuals (393 males and 487 females) in the 1992-93 nutritional survey and 429 individuals (205 males and 224 females) in the 2002-03 nutritional and health survey. The subjects' ages ranged from 18 to 74 years. RESULTS: Mean total cholesterol decreased from 5.3 to 5.1 mmol l(-1) (P < 0.005), and the prevalence of hypercholesterolaemia decreased, especially in males (from 23% to 10% in males from 50 to 64 years old, P < 0.05). Mean cholesterol high-density lipoprotein (HDL) values decreased in the entire sample (from 1.4 to 1.3 mmol l(-1), P < 0.001) and there was an increase in the percentage of population with low values of HDL (from 10% to 19%, P < 0.001). An increase in the percentage of the population with values of alpha-tocopherol at marginal risk levels (from 6% to 9%) and with low values of beta-carotene (from 59% to 66%) was observed. The mean values for retinol increased in both males (from 1.99 to 2.44 micrommol l(-1), P < 0.001) and females (from 1.69 to 2.29, P < 0.001). CONCLUSION: Although there was a decrease in the percentage of population with hypercholesterolaemia, the decrease in HDL cholesterol worsened the lipid profile of the Catalan population. The increase in the values of some antioxidant vitamins did not affect the entire population since an increase in the number of individuals with marginal values was observed.