Tos ferina en España. Situación epidemiológica y estrategias de prevención y control. Recomendaciones del Grupo de Trabajo de Tos ferina

The impact of smoking on bronchiectasis and its comorbidities

INTRODUCTION

Bronchiectasis, characterized by irreversible bronchial dilatation, is a growing global health concern with significant morbidity. This review delves into the intricate relationship between smoking and bronchiectasis, examining its epidemiology, pathophysiology, clinical manifestations, and therapeutic approaches. Our comprehensive literature search on PubMed utilized MESH terms including 'smoking,' 'smoking cessation,' 'bronchiectasis,' and 'comorbidities' to gather relevant studies.

AREAS COVERED

This review emphasizes the role of smoking in bronchiectasis development and exacerbation by compromising airways and immune function. Interconnected comorbidities, including chronic obstructive pulmonary disease, asthma, and gastroesophageal reflux disease, create a detrimental cycle affecting patient outcomes. Despite limited studies on smoking cessation in bronchiectasis, the review stresses its importance. Advocating for tailored cessation programs, interventions like drainage, bronchodilators, and targeted antibiotics are crucial to disrupting the inflammatory-infection-widening cycle.

EXPERT OPINION

The importance of smoking cessation in bronchiectasis management is paramount due to its extensive negative impact on related conditions. Proactive cessation programs utilizing technology and targeted education for high-risk groups aim to reduce smoking's impact on disease progression and related comorbidities. In conclusion, a personalized approach centered on smoking cessation is deemed vital for bronchiectasis, aiming to improve outcomes and enhance patients' quality of life in the face of this complex respiratory condition.

Diagnostic study of pertussis using PCR in primary care clinics

INTRODUCTION

Pertussis is a respiratory infection caused by bacteria of the genus Bordetella, mainly pertussis and parapertussis species. Despite the high vaccination coverage in developed countries, it is considered a re-emerging disease that is also underreported and underdiagnosed, especially in patients who do not require hospital referral.

MATERIAL AND METHODS

Descriptive, prospective and multicentre study of pertussis diagnosis and contact investigation in 17 primary care paediatric clinics through collection of samples for polymerase chain reaction (PCR) testing over a period of 4 years and after the implementation of routine vaccination against pertussis during pregnancy.

RESULTS

Pertussis was diagnosed in a total of 50 patients; the estimated incidence in these years was higher compared to previous rates in the paediatric age group. Fourteen percent of the cases occurred in children aged less than 1 year. The mean age was 6.7 years. Cough was present in 100% of cases, followed in frequency by vomiting and rhinorrhoea. Only 1 patient required hospital admission, and none died or developed complications. B. pertussis was the predominant causative agent. Only 40% knew the source of infection. In 26% of the cases, pertussis was confirmed in contacts of the patient by PCR, and in 46% it was suspected based on the clinical presentation but without microbiological confirmation.

CONCLUSIONS

Access to diagnostic tests (PCR) for pertussis in primary care allows us to optimise its diagnosis and treatment, to break the chain of transmission, to know the real incidence rates and to assess the impact of routine vaccination of pregnant women on this disease.

Direct Medical Costs of Four Vaccine-Preventable Infectious Diseases in Older Adults in Spain

OBJECTIVE

Protection against vaccine-preventable diseases is especially relevant in older adults due to age-related decline in immunity (immunosenescence). However, adult vaccination remains a challenge with overall low coverage rates, which has an impact on both the patients who have these diseases and the health care system in terms of resource use and costs derived. This study aimed to estimate the direct economic impact of herpes zoster, pneumococcal disease, influenza and pertussis in Spanish adults 45 years and older.

METHODS

Data from 2015 were extracted from two Spanish public databases: the Minimum Basic Data Set for Hospitalisations and the Clinical Database of Primary Care. Codes from the International Classification of Diseases and the International Classification of Primary Care were used to identify and classify the diseases analysed. The variables extracted and calculated were hospitalisation (cases, percentage, length of stay, costs, mortality), primary care (cases, percentage, costs) and referrals (cases, percentage, costs). Results were presented for the age groups 45-64 years, 65-74 years, > 74 years and all ages.

RESULTS

In adults 45 years and older, total costs amounted to €134.1 million in 2015 (i.e. 63.9% of the total direct costs for all age groups): 44.4% due to pneumococcal disease, 39.5% due to influenza, 16.0% due to herpes zoster and 0.1% due to pertussis. Hospitalisations represented 58.1% (€77.9 million) of the total costs, with 15,910 admissions, 144,752 days of hospitalisation and 1170 deaths. Primary care registered 566,556 visits with a cost of €35.0 million, and 269,186 referrals with a cost of €21.1 million.

CONCLUSION

The direct economic burden of herpes zoster, pneumococcal disease, influenza and pertussis in adults 45 years and older was high in Spain, and may be underestimated as it only considered medical assistance and not other applicable direct or indirect costs. Increasing vaccination rates in adults may potentially reduce the economic burden derived from these diseases, although future cost-effectiveness analysis including other disease-related costs, vaccination costs and vaccination effectiveness would be needed.

Vaccination in pregnancy against pertussis and seasonal influenza: key learnings and components from high-performing vaccine programmes in three countries: the United Kingdom, the United States and Spain

BACKGROUND

Pertussis and seasonal influenza are responsible for significant maternal, neonatal, and infant morbidity and mortality, but vaccine coverage rates (VCR) for both pertussis (administered as a tetanus, diphtheria, acellular pertussis [Tdap] vaccination) and seasonal influenza in pregnancy remain generally low. Only a small number of countries, including Spain, the United Kingdom (UK), and the United States (US), have high Tdap and seasonal influenza VCRs in pregnancy. The purpose of this study was to identify the key factors that contributed to the high VCRs observed in these countries.

METHODS

The experience from both Tdap and seasonal influenza vaccination programmes during pregnancy were documented in Spain, the UK, and the US using a three-step approach. A literature review yielded 157 publications, and a further 117 documents were selected through desk research. A published five-pillar VCR framework for influenza was amended to evaluate the specific contributing factors leading to high Tdap and seasonal influenza VCRs among pregnant women.

RESULTS

The analysis identified components that contributed to higher VCR in pregnant women across three different healthcare systems in Spain, UK, and US. The combination of several key interventions in each country led to a rapid increase in VCR that reached near-optimal levels (i.e. 75% for seasonal influenza) within a few years. As well as inclusion in national immunisation programme and vaccine reimbursement, key components that were identified included the mobilisation of health authorities, prenatal care Healthcare Professionals (HCP) and scientific societies, the inclusion of vaccination in antenatal medical guidance, the provision of educational material to HCPs, and a strong disease awareness driven by recent pertussis outbreaks in each country.

CONCLUSIONS

Although there is no simple, universal solution to improving sub-optimal VCRs, the list of components identified in this study from three countries with high-performing Tdap and seasonal influenza vaccination programmes provides a basis for public health and medical stakeholders in other countries to define strategies to successfully implement national vaccination programmes for pregnant women.

[Vaccination against community acquired pneumonia in adults. Update 2021 of the position paper by Neumoexpertos en Prevención Group]

Community-acquired pneumonia (CAP) continues to be an important cause of morbidity and mortality in adults. The aim of this study is to update the practical prevention guide for CAP through vaccination in Spain developed in 2016 and updated in 2018, based on available vaccines and evidence through bibliographic review and expert opinion. The arrival of COVID-19 as a new cause of CAP and the recent availability of safe and effective vaccines constitutes the most significant change. Vaccines against pneumococcus, influenza, pertussis and COVID-19 can help to reduce the burden of disease from CAP and its associated complications. The available evidence supports the priority indications established in this guide, and it would be advisable to try to achieve a widespread dissemination and implementation of these recommendations in routine clinical practice.

[Access to complementary tests for the diagnosis of infectious diseases in primary care paediatric clinics]

INTRODUCTION

The performing of complementary tests in infectious processes can increase the diagnostic precision, the adequacy of treatments, as well as determining the epidemiology and pattern of bacterial resistance of the community. The Infectious Pathology Group of the Spanish Association of Primary Care Paediatrics (GPI-AEPap) has designed this study in order to determine the availability of complementary tests (CT) for paediatricians working in Primary Care of the public health system as well as their results.

MATERIAL AND METHODS

Observational cross-sectional descriptive national study was carried out using a voluntary self-report questionnaire distributed online to all AEPap members and to the subscribers of the PEDIAP distribution list between the months of April and May 2017.

RESULTS

A total of 517 responses were obtained. An analysis was made of the data from the professional environment, as well as those related to the request for basic supplementary tests (blood count, biochemistry, and routine urine analysis), the use of Rapid Antigen Detection Test for group A Streptococcus, bacterial cultures, serology, diagnostic tests for pertussis and tuberculosis (Mantoux), as well as imaging tests.

CONCLUSIONS

There is variability between Autonomous Communities and healthcare areas. Areas for improvement were found in the accessibility to different CT, collection time and sending of samples, delay in receiving results, as well as waiting times for non-urgent imaging tests. These affect the intervention and resolution capacity of the primary care paediatrician.

Population dynamics and antigenic drift of Bordetella pertussis following whole cell vaccine replacement, Barcelona, Spain, 1986-2015

Among the factors associated with the resurgence of whooping cough, special emphasis has been given to pathogen adaptation after the introduction of the acellular vaccine (ACV). To assess the impact of the vaccine transition strategy from whole-cell vaccine (WCV) to ACV on population dynamics of Bordetella pertussis in Barcelona (Spain), we studied 339 isolates collected from 1986 to 2015 by PFGE and multi-locus variable-number tandem repeat analysis (MLVA). Additionally, allelic variants for the pertussis toxin and its promoter, pertactin, type 3 fimbriae and fimbrial serotyping were assessed to determine its antigenic drift. A shift was observed in the B. pertussis population as well as in its antigenic profile concurrently with the introduction of ACV in Barcelona. Four out of the five most prevalent PFGE profiles were replaced by new profiles following the ACV introduction. MLVA type 27 was the dominant genotype, and its frequency increased from 25% to 79.3% after WCV replacement. Antigen typing demonstrated the emergence of prn2, ptxP3, fim3-2 and a shift from the fimbriae 3 to the fimbriae 2 serotypes after the ACV introduction. Our findings support the presence of population and antigenic dynamic changes in B. pertussis likely driven by the introduction of ACV.

Proper pertussis vaccination will probably not increase vaccination coverage: a case-control study

Vaccination coverage (VC) against pertussis can increase when management practices and policies at primary care centres (PCCs) are reinforced. From 2011 to 2015, we performed a case-control study to evaluate VC among pertussis patients treated at PCCs in Barcelona, Spain. We recorded pertussis in patients from 8- to 16-year-olds at 52 PCCs. Pertussis cases had laboratory diagnostic and controls were healthy outpatients visiting the same facility for reasons other than cough. DTaP/dTap VC was recorded as either proper vaccination status (five doses recorded) or improper vaccination status (<5 doses recorded). We used a logistic regression model to estimate OR and 95% CI. We included 229 cases and 576 controls. VC was higher in cases (mean 5.01, s.e.: 0.57) than in controls (4.89, s.e.: 0.73). Around 69% of the cases had received DTaP primary immunisation after 2-5 years and 31.4% of cases had the dTap booster immunisation after 7-10 years. The 87% of children 5-9 years were properly vaccinated. We found no protection from becoming ill among properly vaccinated children (OR 1.87; 95% CI 1.22-2.85). The highest VC was observed in patients with confirmed pertussis, which was likely due to a more exhaustive follow-up of the VC in these patients. Being properly vaccinated against pertussis will probably not increase VC.

Attributes influencing parental decision-making to receive the Tdap vaccine to reduce the risk of pertussis transmission to their newborn - outcome of a cross-sectional conjoint experiment in Spain and Italy

Pertussis vaccination of parents and household contacts (‘cocooning’) to protect newborn infants is an established strategy in many countries, although uptake may be low. Many aspects may influence such decision-making. We conducted a cross-sectional survey (NCT01890447) of households and other close contacts of newborns aged ≤6 months (or of expectant mothers in their last trimester) in Spain and Italy, using an adaptive discrete-choice experiment questionnaire. Aims were to assess the relative importance of attributes influencing vaccine adoption, and to estimate variation in vaccine adoption rates and the impact of cost on vaccination rates. Six hundred and fifteen participants (Spain, n = 313; Italy, n = 302) completed the survey. Of 144 available questionnaire scenarios, the most frequently selected (14% of respondents in both countries) were infant protection by household vaccination at vaccination center, recommendation by family physician and health authorities, with information available on leaflets and websites. The attribute with highest median relative importance was ‘reduction in source of infection’ in Spain (23.1%) and ‘vaccination location’ in Italy (18.8%). Differences between other attributes were low in both countries, with media attributes showing low importance. Over 80% of respondents indicated a definite or probable response to vaccine adoption (at no-cost) with estimated probability of adoption of 89–98%; applying vaccine costs (25€ per person) would reduce the probability of uptake by 7–20% in definite/probable respondents. Awareness of these determinants is helpful in informing Health Authorities and healthcare practitioners implementing a cocooning strategy for those populations where maternal immunization is not a preferred option.

Clinical-epidemiological study of Bordetella pertussis infection in the Gran Canaria island in the period, 2008-2016

OBJECTIVE

Describe the epidemiological and clinical pattern of Bordetella pertussis infection (whooping cough) among hospitalised infants less than one year-old in a paediatric hospital in Gran Canaria.

PATIENTS AND METHODS

A retrospective review of the patient hospital records was performed, and recording only those with a microbiological diagnosis of pertussis infection detected using polymerase chain reaction, from January 2008 to December 2016.

RESULTS

A total of 110 patients were identified, of which 105 (95.4%) were less than 6 months old, and 59.1% were males. The annual incidence of hospital admissions was estimated between 13.7 and 425.0 cases per 100 000 infants <12 months old, with 2 peaks in 2011 and 2015. Household members were the main potential sources of infection. Main clinical features were pertussis cough associated with signs of catarrh, cyanosis, and lymphocytosis. Complications occurred in 15.4% of the patients (mainly pneumonia), but the outcome was favourable in all the cases. A lower age and non-vaccination were associated with an increased risk of developing complications (p < .05). Viral co-infection occurred in 31.6% of infants diagnosed with pertussis.

CONCLUSIONS

The incidence of pertussis has increased in the last years in Gran Canaria, with a lower development of complications and mortality rates compared with the previous period. Lower age and non-vaccination status are considered risk factors for developing complications. Vaccination in pregnant women will probably lead to a decline in the incidence in the future, especially in infants younger than 6 months.

[Clinical-epidemiological study of Bordetella pertussis infection in the Gran Canaria island in the period, 2008-2016]

OBJECTIVE

Describe the epidemiological and clinical pattern of Bordetella pertussis infection (whooping cough) among hospitalised infants less than one year-old in a paediatric hospital in Gran Canaria.

PATIENTS AND METHODS

A retrospective review of the patient hospital records was performed, and recording only those with a microbiological diagnosis of pertussis infection detected using polymerase chain reaction, from January 2008 to December 2016.

RESULTS

A total of 110 patients were identified, of which 105 (95.4%) were less than 6 months-old, and 59.1% were males. The annual incidence of hospital admissions was estimated between 13.7 to 425.0 cases per 100,000 infants <12 months old, with 2peaks in 2011 and 2015. Household members were the main potential sources of infection. Main clinical features were pertussis cough associated with signs of catarrh, cyanosis, and lymphocytosis. Complications occurred in 15.4% of the patients (mainly pneumonia), but the outcome was favourable in all the cases. A lower age and non-vaccination were associated with an increased risk of developing complications (P<.05). Viral co-infection occurred in 31.6% of infants diagnosed with pertussis.

CONCLUSIONS

The incidence of pertussis has increased in the last years in Gran Canaria, with a lower development of complications and mortality rates compared with the previous period. Lower age and non-vaccination status are considered risk factors for developing complications. Vaccination in pregnant women will probably lead to a decline in the incidence in the future, especially in infants younger than 6 months.

Influence of health literacy on acceptance of influenza and pertussis vaccinations: a cross-sectional study among Spanish pregnant women

OBJECTIVES

Immunisations against influenza and Bordetella pertussis infection are recommended to pregnant women in Valencia (Spain), yet vaccination rates remain low. Health literacy (HL) appears as a crucial factor in vaccination decision-making. We explored the relation between HL of pregnant women and decisions to receive influenza and pertussis immunisations.

SETTING

University hospital in Valencia (Spain).

PARTICIPANTS

119 women who gave birth at a hospital in Valencia (Spain) between November 2015 and May 2016. Women in the immediate postpartum period (more than 27 weeks of gestation), between November 2015 and May 2016 were included in the study. Women with impairments, language barriers or illiteracy which prevented completion of the questionnaires, or those who were under 18 years were excluded from enrolment.

PRIMARY AND SECONDARY OUTCOME MEASURES

HL level; influenza and pertussis immunisation rate; reasons for rejection of vaccination.

RESULTS

119 participants were included (mean age 32.3±5.5 years, 52% primiparous, 95% full-term deliveries). A higher education level was associated with Short Assessment of Health Literacy for Spanish Adults _50 (adjusted R²=0.22, p=0.014) and Newest Vital Sign (adjusted R²=0.258, p=0.001) scores. Depending on the scale, 56%-85% of participants had adequate HL. 52% (62/119) and 94% (112/119) of women received influenza and pertussis immunisation, respectively. Women rejecting influenza vaccine had a higher HL level (measured by SALHSA_50 tool) than those accepting it (Kruskal-Wallis test p=0.022). 24% of women who declined influenza vaccination felt the vaccine was unnecessary, and 23% claimed to have insufficient information.

CONCLUSIONS

Influenza vaccination rate was suboptimal in our study. Women with high HL were more likely to decline immunisation. Information from professionals needs to match patients' HL levels to reduce negative perceptions of vaccination.

Epidemiology of pertussis in two Ibero-American countries with different vaccination policies: lessons derived from different surveillance systems

Background

Pertussis is a re-emerging disease worldwide despite its high vaccination coverage. European and Latin-American countries have used different surveillance and vaccination policies against pertussis. We compared the epidemiology of this disease in two Ibero-American countries with different vaccination and surveillance policies.

Methods

We compared the epidemiology of pertussis in Spain and the Dominican Republic (DR). We present a 10-year observational study of reported pertussis based on suspected and/or probable cases of pertussis identified by the national mandatory reporting system in both countries between 2005 and 2014. Both countries have a similar case definition for pertussis surveillance, although Spain applies laboratory testing, and uses real time PCR and/or culture for case confirmation while in DR only probable and/or suspected cases are reported. We analyzed incidence, hospitalization, case-fatality rates, mortality and vaccination coverage.

Results

The average annual incidence in children aged <1 year was 3.40/100,000 population in Spain and 12.15/100,000 in DR (p = 0.01). While the incidence in DR was generally higher than in Spain, in 2011 it was six times higher in Spain than in DR. The highest infant mortality in Spain was 0.017/100,000 in 2011, and the highest in DR was 0.08/100,000 in 2014 (p = 0.01). The proportion of hospitalized cases per year among children <1 year varied between 22.0% and 93.7% in Spain, and between 1.1% and 29.4% in DR (p = 0.0002), while mortality varied from 0 to 0.017 and 0 to 0.08 per 100,000 population in Spain and DR, respectively (p = 0.001). Vaccination coverage was 96.5% in Spain and 82.2% in DR (p = 0.001).

Conclusions

Pertussis is a public health problem in both countries. Surveillance, prevention and control measures should be improved, especially in DR. Current vaccination programs are not sufficient for preventing continued pertussis transmission, even in Spain which has high vaccination coverage.

Vaccination coverage against pertussis in pregnant women of Catalonia in the first year of implementation of the immunisation program

INTRODUCTION

The re-emergence of pertussis and the severity of its complications in infants younger than 3 months, were determining factors for starting a vaccination program for pregnant women in the third trimester of gestation in Catalonia in February 2014. This was the first autonomous community to introduce it in Spain. The aim of the study was to estimate the coverage of the program in its first year of implementation.

METHODS

A retrospective analysis was performed on the data from the Primary Care Centre computerised medical records of pregnant women attending Sexual and Reproductive Health Care centres of the Metropolitan Nord area of the province of Barcelona, part of the Catalan Institute of Health. The overall coverage was estimated, as well as the sociodemographic variables of Tdap vaccination of women who had registered a delivery of a live birth between August 2014 and August 2015.

RESULTS

A total of 6,697 deliveries of live births were recorded, and 1,713 pregnant women were vaccinated, which represented an overall coverage of 25.6% (95% CI; 24.1-26.1). Vaccination coverage was higher in pregnant women under 18 years and Spanish women (P=.018 and P=.036, respectively).

CONCLUSION

The estimation of vaccine coverage against pertussis in pregnant women in the third trimester of pregnancy, after the first year of implementation of the program in a health area of Catalonia was lower than the objective set. Strategies need to be designed in order to improve program coverage.

Pertussis: Microbiology, Disease, Treatment, and Prevention

Pertussis is a severe respiratory infection caused by Bordetella pertussis, and in 2008, pertussis was associated with an estimated 16 million cases and 195,000 deaths globally. Sizeable outbreaks of pertussis have been reported over the past 5 years, and disease reemergence has been the focus of international attention to develop a deeper understanding of pathogen virulence and genetic evolution of B. pertussis strains. During the past 20 years, the scientific community has recognized pertussis among adults as well as infants and children. Increased recognition that older children and adolescents are at risk for disease and may transmit B. pertussis to younger siblings has underscored the need to better understand the role of innate, humoral, and cell-mediated immunity, including the role of waning immunity. Although recognition of adult pertussis has increased in tandem with a better understanding of B. pertussis pathogenesis, pertussis in neonates and adults can manifest with atypical clinical presentations. Such disease patterns make pertussis recognition difficult and lead to delays in treatment. Ongoing research using newer tools for molecular analysis holds promise for improved understanding of pertussis epidemiology, bacterial pathogenesis, bioinformatics, and immunology. Together, these advances provide a foundation for the development of new-generation diagnostics, therapeutics, and vaccines.

Tendencia de la mortalidad y morbilidad por tos ferina en Colombia 2002-2012

<p class="Default"><strong>Introducción.</strong> La tos ferina es un problema de salud pública que afecta principalmente a niños menores de un año en quienes los desenlaces son altamente letales; es una enfermedad reemergente, prevenible con inmunización.</p><p><strong>Objetivo.</strong> Analizar la tendencia de la mortalidad y morbilidad por tos ferina en Colombia entre los años 2002-2012.</p><p><strong>Materiales y métodos.</strong> Estudio descriptivo cuantitativo de las muertes por tos ferina entre 2002-2012 con fuente de información secundaria según certificados de defunción del Departamento Administrativo Nacional de Estadística, y casos reportados al Sistema Nacional de Vigilancia en Salud Pública 2005-2012. Se calcularon medidas de frecuencia, tasas de morbilidad y mortalidad y sobremortalidad femenina.</p><p><strong>Resultados.</strong> El 51,2% de las muertes ocurrieron en mujeres; el año con más defunciones fue 2012; el 67,3% pertenecían al área urbana y el 43,5% estaban afiliados al régimen subsidiado de salud. El riesgo de enfermar fue de 1,88 por mil nacidos vivos con mayor riesgo en Vaupés y Vichada. El riesgo de morir fue de 0,02 por mil nacidos vivos; la tendencia de la letalidad mostró disminución.</p><p><strong>Conclusión.</strong> La mortalidad y morbilidad por tos ferina ha mostrado reemergencia; al ser esta una enfermedad prevenible por medio de la vacunación se recomienda mayor control y mejora en las coberturas de vacunación tanto en niños como en adultos que son un importante reservorio de la enfermedad; para un efectivo control de la tos ferina se recomienda un trabajo continuo orientado a su identificación oportuna; también es preciso adelantar acciones para mejorar la calidad del dato con el fin de facilitar análisis y generación de información cada vez más válida.</p>

Seroprevalence of pertussis amongst healthcare professionals in Spain

INTRODUCTION

This multi-center, hospital-based observational study determined the seroprevalence of pertussis antibodies amongst healthcare professionals from three different hospitals in Spain to ascertain the health status of professionals attending to susceptible groups who are at risk of contracting and transmitting pertussis.

METHODS

Medical professionals from three hospitals in Spain were recruited for this study (NCT01706224). Serum samples from subjects were assessed for anti-pertussis antibodies by ELISA. The percentage of subjects positive for anti-pertussis antibodies were determined by age-strata, gender, vaccination status, professional level (physicians, nurses, ancillary nurses and midwives), hospital department, number of working years, numbers of hours spent with the patient as well as number of children in the household.

RESULTS

Overall, 31.2% of subjects were seropositive; 3.3% of these healthcare professionals had ELISA values indicative of current or recent infection. There were no significant differences in terms of pertussis prevalence with respect to age, gender, hospital department, profession, number of working years and number of hours spent with patients. These levels of seronegativity amongst healthcare workers further strengthen the rationale for vaccination amongst this specific population against pertussis.

[Is it ethically acceptable to invite a pregnant woman to enroll in a clinical trial with Tdap if it could entail not being vaccinated with Tdap before delivery?]

Pertussis incidence has increased in recent years, especially among infants aged <2months. A number of Spanish regions have started a vaccination program with Tdap vaccine to all pregnant women in the third trimester of pregnancy. An observational study has shown that this strategy reduces the number of cases of pertussis by 90% in infants aged <2months. Mathematical models showed that a cocooning strategy (i.e. vaccination of the mother at immediate postpartum, and other adults and adolescents who have close contact with the newborn and caregivers) will reduce the incidence of pertussis by 70% in infants aged <2months. It is intended to conduct a clinical trial in which 340 pregnant women will receive Tdap vaccine, whereas another 340 pregnant woman will be vaccinated soon after delivery. Vaccination with Tdap will be offered to all partners and caregivers of the newborn. After assessing both the ethical and scientific reasons supporting the trial, it is concluded that it is ethically and legally acceptable to invite pregnant women living in communities where Tdap vaccination has been implemented to participate in the trial.

Importance of Enhanced Surveillance for Prevention of Pertussis in Children

BACKGROUND

Bordetella pertussis infection causes considerable morbidity, even in countries with high vaccination coverage. Surveillance of pertussis is usually passive and based on mandatory reporting. We assessed the epidemiologic and clinical characteristics of pertussis cases detected by passive or enhanced surveillance.

METHODS

A prospective population-based study was carried out from January 2012 to December 2013 in Catalonia and Navarre, 2 Spanish regions with a total population of 8.2 million. For each confirmed case, variables of age, sex, clinical symptoms, laboratory results and vaccination status were investigated. Associations between the variables studied and the type of surveillance were assessed by odds ratio (OR) and its 95% confidence interval (CI). Logistic regression was used to estimate adjusted OR (aOR).

RESULTS

In children <18 years of age, passive surveillance was the most important source of detection (95.7% in <1 year). In children 5-10 years of age, passive surveillance detected 67.5% of cases. In those ≥18 years, enhanced surveillance was the most frequent source of case detection (82.5%). Inspiratory whoop (aOR: 1.94; 95% CI: 1.40-2.70), apnea (aOR: 1.92; 95% CI: 1.28-2.87) and posttussive vomiting (aOR: 1.43; 95% CI: 1.04-1.96) were symptoms included in the clinical case definition that were associated with passive surveillance.

CONCLUSIONS

Underreporting of symptomatic cases is important not only in adults, but also in children >1 year of age and suggests that providing clinics with free, fast laboratory diagnostic tests, together with enhanced surveillance of family contacts of any age is necessary to better determine existing cases. Enhanced surveillance may be helpful to better understand transmission patterns in the family and in the community.

[Acellular vaccines (DTPa/dTpa) against whooping cough, protection duration]

INTRODUCTION

An increase in whooping cough in most of the developed countries has been detected in the last decade.

OBJECTIVE

To determine whether the administration of dTpa vaccine instead of DTPa fifth dose is contributing to the appearance of these cases.

METHODS

A descriptive study based on cases of whooping cough reported during an epidemic period in the city of Alicante in the first 5 months of 2014. Only pertussis cases confirmed by PCR were included in the study, and only those vaccinated with 5 doses were included in the analysis of the period of protection.

RESULTS

A total of 104 cases of pertussis confirmed by PCR were reported, with 85 cases (82%) having had 5 doses of vaccine. The mean time and standard deviation (SD) of protection was 2.1±1.1 years with dTpa, and 5.1±1.5 years with DTPa (p<.001). In the protection, adjusted for age, it was observed that, after 3 years, only 47.6% of people vaccinated with dTpa were still protected, while people vaccinated with DTPa were 100% protected (P<.001).

CONCLUSIONS

This study found that people who were properly vaccinated against pertussis and received their last re-vaccination dose with dTpa had a shorter period of protection than those who were vaccinated with DTPa.

[Pertussis vaccine. Reemergence of the disease and new vaccination strategies]

Pertussis continues to be a public health problem despite the significant decrease in its incidence due to routine vaccination. Resurgence of the disease in countries that have maintained high vaccination coverage has been observed in recent years. Although vaccination is the most effective preventive control measure, both natural and artificial immunity wane over time, and thus the protection offered by current vaccines is not long-lasting. Furthermore, acellular vaccines are less effective. The implementation of new vaccine strategies is required. Vaccination of pregnant women is the most effective strategy for preventing pertussis in young infants, who are the most vulnerable, and should be recommended together with cocooning, ie vaccination of future household and extra-domiciliary contacts who are the main transmitters of the disease.

Evaluation of reported cases of pertussis: epidemiological study in a large city in Spain

We retrospectively analysed the incidence rate of reported cases of pertussis in Barcelona during 2009–2012 according to age, sex, type of medical centre and vaccination status. We included 748 confirmed or suspected cases, 613 (82.0 %) of which were confirmed by laboratory testing and the remaining 135 (18.0 %) by epidemiological evidence. The highest reported incidence of pertussis was amongst <1 year olds [96.1 per 100 000 person-years, 95 % confidence interval (CI): 84.3–109.1]. The majority of confirmed and suspected cases were reported in 2011 and 2012, and the total incidence (confirmed or suspected) was 6.3 (95 % CI: 5.6–6.9) and 4.2 (95 % CI: 3.6–4.7) per 100 000 person-years, respectively. Incidence increased significantly (P = 0.001) in 2011–2012 compared with 2009. Most confirmed cases occurred in children <1 year old (87.9 %). Cases were confirmed by real-time (RT)-PCR (87.5 %; 95 % CI: 81.3–87.6) and bacterial culture (13.7 %; 95 % CI: 11.0–17.1). We recommend performing RT-PCR in suspected cases with no epidemiological link to a confirmed case.

[Incidence and severity of pertussis in infants with a respiratory syncytial virus infection]

INTRODUCTION

Pertussis is a re-emerging disease that mostly affects infants. At this age, the severity can be affected by intercurrent infections such as respiratory syncytial virus (RSV).

OBJECTIVES

To estimate the incidence of RSV infection during an epidemic period in patients hospitalized due to pertussis. The impact on the severity was also observed during hospitalization.

PATIENTS AND METHOD

A descriptive study of cases diagnosed with pertussis admitted to a tertiary hospital over a 3year period, where the presence of co-infection with RSV was analyzed. The estimate of severity was estimated using the incidence of complications and the level of care required.

RESULTS

From a total of 73 infants with pertussis, 34 occurred in a bronchiolitis season epidemic. A co-infection due to RSV was detected in 17 patients. The mean age was not significantly different compared to the non co-infected. The mean stay and the need for intensive care was similar in both groups. The need for oxygen therapy care and nutritional support was higher in the coinfected patients.

CONCLUSIONS

Coinfection with RSV in infants hospitalized with pertussis occurred in ono in 2 patients during a RSV epidemic season, in infants of similar age. Severity in terms of stay, presence of apnea and admission to intensive care was similar, but more need for respiratory care and nutritional support was found.

Pertussis

Pertussis continues to be an important public-health issue. The high immunization coverage rates achieved, mainly in industrialized countries, have certainly decreased the spread of the pathogen. However, as immunity wanes, adolescents and adults play an important role in the dynamics of the infection. The surveillance system has several limitations and the underestimation of pertussis in adolescents, young adults and adults is mainly related to the atypical clinical characteristics of cases and the lack of lab confirmation. The real epidemiological impact of pertussis is not always perceived. The unavailability of comprehensive data should not hamper the adoption of active prophylactic measures designed to avoid the impact of waning immunity against pertussis. Different immunization strategies have been suggested and/or already adopted such as immunization of newborns, pre-school and school children, adolescents, adults, healthcare workers, childcare workers, pregnant women, cocoon strategy. Prevention of pertussis requires an integrated approach and the adoption of different immunization strategies, with the objective of achieving and maintaining high coverage rates.

Seroprevalence study of B. pertussis infection in health care workers in Catalonia, Spain

Pertussis is a re-emerging infection in countries with high infant immunization coverage. Healthcare workers (HCW) are exposed and can transmit the infection to especially-vulnerable patients. Therefore, pertussis vaccination of HCW is recommended. Between June 2008 and December 2010, 460 HCW from hospital and primary healthcare centers were recruited to determine susceptibility to pertussis. IgG antibodies against pertussis (anti-pertussis ab) were measured, using a routine technique that detects antibodies against pertussis including pertussis toxin (PT) and filamentous hemagglutinin (FHA). Positive results were confirmed with a more-specific technique that only assesses anti-PT IgG antibodies. The median age was 42 years (range, 21-65), 77.3% were female. 172 were nurses, 133 physicians, 60 other clinical workers and 95 non-clinical workers. None had received pertussis vaccination since childhood. The overall prevalence of anti-pertussis antibodies was 51.7%, (95% CI 47.1-56.4). Anti-PT antibodies were determined in the 220 HCW with positive anti-pertussis antibodies: 4 (1.8%) were negative and 33 (15%) had a high titer (≥ 45 IU/mL). No significant differences between the prevalence of anti-pertussis antibodies or anti-TP antibodies were found according to age, type of occupation or type of center. Our study confirms the need for vaccination of HCW because at least half are susceptible to pertussis. High anti-PT titers found in 15% of seropositive HCW showed that they had had recent contact with B. pertussis.

Geographical differences in whooping cough in Catalonia, Spain, from 1990 to 2010

Background

Whooping cough is a communicable disease whose incidence has increased in recent years in some countries with vaccination. Since 1981, in Catalonia (Spain), cases must be reported to the Public Health Department. In 1997, surveillance changed from aggregated counts to individual report and the surveillance system was improved after 2002. Catalan public health is universal with equal coverage geographically. The aim of this study was to determine whether there are differences in whooping cough incidence in rural and urban counties.

Methods

Cases in 1990–2010 were classified as rural or urban. Incidences and risk ratios (RR) between urban and rural counties and 95% CI were calculated. Associations between rural and urban counties and structural changes during the study period were analysed.

Results

Twelve years of the whole study period showed differences in incidence between rural and urban counties. The incidence was higher in urban counties in seven years and rural counties in five years. There was a positive association of whooping cough incidence in rural and urban counties in four-week periods. Structural changes were detected in the following four-week periods: 4^th in 1993, 7^th in 1996 and 3^rd 2005 in rural counties and 5^th 1993, 9^th in 1996 and 8^th in 2007 in urban counties.

Conclusions

Differences in whooping cough between rural and urban counties were found. In most years, the incidence was higher in urban than in rural counties. Rural and urban counties show similar cyclic behaviour when four-week periods were considered.

[General epidemiology of infections acquired by health-care workers: immunization of health-care workers]

Healthcare workers are exposed to multiple occupational hazards, the most common being the biological risk. Moreover, colonized staff, or those in incubation period, or with an active infectious disease, could be at risk of transmitting these infections to others, such as patients, relatives or other workers. Therefore, measures to prevent biological risks in the healthcare environment are essential. In this chapter, the main recommendations for the prevention and control of infectious diseases that can affect health care personnel are reviewed. Specific measures recommended for each infection, including vaccination guidance, are described. These recommendations were updated according to the available evidence and the epidemiological changes described in recent years.

Consensus document for the prevention of respiratory infections in adults

Infectious diseases are one of the principle causes of morbidity, mortality and drain on health resources worldwide. In recent years there has been an increase in the impact of respiratory infections, particularly in the Portuguese population. It is for this reason that the Portuguese Respiratory Society has presented a series of recommendations for the prevention of respiratory infections in adults. These recommendations include both general measures and vaccinations for flu and pneumococcal pneumonia.

[Hospitalization due to whooping cough in Spain (1997-2011)]

INTRODUCTION

Pertussis incidence has increased in recent years in countries with high vaccination coverage. The aim of this study was to determine the health impact of pertussis in Spain in the period 1997-2011 in relation to hospitalizations, mortality, and associated costs.

METHODS

We retrospectively analyzed hospital discharges included in the Minimum Data Set (MDS) in Spain for the period 1997-2011, with a primary or secondary diagnosis related to pertussis. We calculated incidence rates of hospitalization for pertussis (per 100,000) per year, by age group and by Autonomous Region, along with the mortality and lethality rates.

RESULTS

A total of 8,331 hospital discharges with a diagnosis of pertussis were recorded in Spain between 1997 and 2011. The overall incidence of pertussis hospitalizations was 1.3 cases per 100,000 inhabitants. The large majority (92%) of hospitalizations occurred in children under one year of age, with an incidence of 115.2 hospitalizations per 100,000. There were 47 deaths, 37 (79%) in the group of children under 1 year and 6 (13%) in the group older than 65 years. The estimated cost of hospitalization for pertussis was 1,841 euros.

CONCLUSION

The epidemiology of severe cases of pertussis, and its clinical and economic impact, confirms the need to modify the vaccination strategies for Spain to achieve more effective control in the most vulnerable groups.