The role of viral diagnostic tests in respiratory tract infections: moving forward

The increased knowledge on virology and the increased potential of their diagnostic has risen several relevant question about the role of an early viral diagnosis and potential early treatment on the management of respiratory tract infections (RTI). In order to further understand the role of viral diagnostic tests in the management of RTI, a panel of experts was convened to discuss about their potential role, beyond what had been agreed in Influenza. The objective of this panel was to define the plausible role of aetiologic viral diagnostic into clinical management; make recommendations on the potential expanded use of such tests in the future and define some gaps in the management of RTI. Molecular Infection Viral Diagnostic (mIVD) tests should be used in all adult patients admitted to Hospital with RTI, and in paediatric patients requiring admission or who would be referred to another hospital for more specialised care. The increased use of mIVD will not only reduce the inappropriate use of antibiotics so reducing the antibiotic microbe resistance, but also will improve the outcome of the patient if an aetiologic viral therapy can be warranted, saving resource requirements and improving patient flows. Implementing IVD testing in RTI has various organizational benefits as well, but expanding its use into clinical settings would need a cost-effectiveness strategy and budget impact assessment.

[Importance of National Influenza Centers in the surveillance of highly pathogenic avian viruses. The time for One-Health is now]

Since 1996, the highly pathogenic avian influenza subtype A(H5N1) has been causing almost uninterrupted outbreaks in wild and domestic birds, as well as cases in humans with a mortality rate close to 50%. However, the years of greatest circulation have been precisely the years following the COVID-19 pandemic, in which several cases have been recorded in humans in places where they had never appeared before, in addition to multiple cases in wild, domestic and peri-domestic mammals, which raise some concern about the risk that the virus may jump to humans through chains of transmission of greater or lesser extent. The current outbreak of A(H5N1) shows us that the One-Health concept should be more alive than ever to join efforts between professionals from different sectors of human, animal and environmental health to avoid or minimize these risks, so that reference laboratories such as the National Influenza Centers have the human and material resources to provide rapid and relevant information in the shortest possible time before emergencies of this type. The diagnostic and monitoring tools to be used in these cases must be available for any eventuality, and going beyond the basic data must be an indispensable premise to be able to carry out a detailed monitoring that serves to limit outbreaks, limit the spread of the disease, and help in the design of future pandemic vaccines against avian viruses.

Microbiological and epidemiological features of respiratory syncytial virus

The properties of the main surface proteins and the viral cycle of the respiratory syncytial virus (RSV) make it an attractive pathogen from the perspective of microbiology. The virus gets its name from the manner it infects cells, which enables it to produce syncytia, which allow the virus' genetic material to move across cells without having to release viral offspring to the cellular exterior, reducing immune system identification. This causes a disease with a high impact in both children and adults over 60, which has sparked the development of several preventive interventions based on vaccines and monoclonal antibodies for both age groups. The epidemiological characteristics of this virus, which circulates in epidemics throughout the coldest months of the year and exhibits a marked genetic and antigenic drift due to its high mutation capability, must be taken into consideration while using these preventive methods. The most important microbiological and epidemiological elements of RSV are covered in this study, along with how they have affected the creation of preventive medications and their use in the future.

The PHH-1V HIPRA vaccine: a new tool in the vaccination strategy against COVID-19

OBJECTIVE

Vaccination against SARS-CoV-2 is essential to mitigate the personal, social and global impact of the coronavirus disease (COVID-19) as we move from a pandemic to an endemic phase. Vaccines are now required that offer broad, long-lasting immunological protection from infection in addition to protection from severe illness and hospitalisation. Here we present a review of the evidence base for a new COVID-19 vaccine, PHH-1V (Bimervax®; HIPRA HUMAN HEALTH S.L.U), and the results of an expert consensus.

METHODS

The expert committee consisted of Spanish experts in medicine, family medicine, paediatrics, immunology, microbiology, nursing, and veterinary medicine. Consensus was achieved using a 4-phase process consisting of a face-to-face meeting during which the scientific evidence base was reviewed, an online questionnaire to elicit opinions on the value of PHH-1V, a second face-to-face update meeting to discuss the evolution of the epidemiological situation, vaccine programmes and the scientific evidence for PHH-1V and a final face-to-face meeting at which consensus was achieved.

RESULTS

The experts agreed that PHH-1V constitutes a valuable novel vaccine for the development of vaccination programmes aimed towards protecting the population from SARS-CoV-2 infection and disease. Consensus was based on evidence of broad-spectrum efficacy against established and emerging SARS-CoV-2 variants, a potent immunological response, and a good safety profile. The physicochemical properties of the PHH-1V formulation facilitate handling and storage appropriate for global uptake.

CONCLUSIONS

The physicochemical properties, formulation, immunogenicity and low reactogenic profile of PHH-1V confirm the appropriateness of this new COVID-19 vaccine.

The Impact of the COVID-19 Pandemic on Influenza Vaccination Attitudes and Actions in Spain's Adult Population

Seasonal influenza is an acute respiratory infection caused by the influenza virus which constitutes a significant public health issue associated with high morbidity and mortality. The aim of this study was to investigate changes in attitudes, perceptions, and practices regarding influenza vaccination in the Spanish adult population during the COVID-19 pandemic, as well as their vaccination intentions, with special attention paid to those over 65 years old and in high-risk groups. To this end, a cross-sectional study was conducted through 2219 telephone interviews, and the results were compared with results obtained a year earlier. Regarding the reasons for deciding to get vaccinated in the 2022/23 season, a significant increase was observed in vaccine confidence (36.7% vs. 42.8%), social responsibility (32.5% vs. 43.8%), and in awareness of the importance of vaccination due to COVID-19 (21.7% vs. 25.4%). Advanced age (OR 2.8, 95% CI 2.0-3.9), belonging to high-risk groups (OR 2.7, 95% CI 2.0-3.7), and prior vaccination (OR 25.3, 95% CI 19.5-32.7) emerged as significant predictors for the intent to receive the influenza vaccine in the 2022/23 season. Continuously observing shifts in perceptions and behaviors related to influenza immunization is crucial to pinpoint factors that may influence the willingness to receive the vaccine and, in this way, design public health strategies that achieve a greater acceptance of it.

Impact of COVID-19 on Adherence to Treatment in Patients with HIV

In patients with human immunodeficiency virus (HIV), adherence to treatment is affected by the adverse effects of treatment, the presence of additional comorbidities, the complexity of dosage, and family and community support. However, one recent circumstance that was likely to have influenced therapeutic adherence was the COVID-19 pandemic and the applied containment measures. An observational retrospective study of a sample of patients with HIV was conducted to establish the relationship between sociodemographic, clinical, and pharmacological variables and therapeutic adherence before and after the pandemic. Adherence was measured using the validated simplified medication adherence questionnaire (SMAQ) and medication possession rate. A statistical analysis was performed to determine the mean, standard deviation, and median of the quantitative variables and the frequencies of the qualitative variables, and the relationship between the dependent and independent variables was analysed using the chi-squared test and Student's t-test. No statistically significant differences were found between treatment adherence measured before and 22 months after the start of the pandemic. Sex, occupation, treatment regimen, viral load levels, and COVID-19 disease status did not influence adherence during either period. However, the age of patients with HIV had an impact on adherence during both periods (p = 0.008 and p = 0.002, respectively), with the age group under 45 years being less adherent. In addition, experiencing adverse drug reactions (ADRs) was shown to have an impact on adherence before the pandemic (p = 0.006) but not afterwards. The COVID-19 pandemic was not shown to have an impact on the degree of adherence to antiretroviral treatment in patients with HIV. Instead, adherence was influenced by patient age and ADR occurrence; therefore, measures must be taken in this regard. The SMAQ demonstrated sensitivity in assessing adherence.

Adjuvants for COVID-19 Vaccines

In recent decades, the improvement of traditional vaccines has meant that we have moved from inactivated whole virus vaccines, which provoke a moderate immune response but notable adverse effects, to much more processed vaccines such as protein subunit vaccines, which despite being less immunogenic have better tolerability profiles. This reduction in immunogenicity is detrimental to the prevention of people at risk. For this reason, adjuvants are a good solution to improve the immunogenicity of this type of vaccine, with much better tolerability profiles and a low prevalence of side effects. During the COVID-19 pandemic, vaccination focused on mRNA-type and viral vector vaccines. However, during the years 2022 and 2023, the first protein-based vaccines began to be approved. Adjuvanted vaccines are capable of inducing potent responses, not only humoral but also cellular, in populations whose immune systems are weak or do not respond properly, such as the elderly. Therefore, this type of vaccine should complete the portfolio of existing vaccines, and could help to complete vaccination against COVID-19 worldwide now and over the coming years. In this review we analyze the advantages and disadvantages of adjuvants, as well as their use in current and future vaccines against COVID-19.

[Validity and usefulness of the RAE-CMBD studying patients hospitalised with influenza]

OBJECTIVE

Understanding the hospital impact of influenza requires enriching epidemiological surveillance registries with other sources of information. The aim of this study was to determine the validity of the Hospital Care Activity Record - Minimum Basic Data Set (RAE-CMBD) in the analysis of the outcomes of patients hospitalised with this infection.

METHODS

Observational and retrospective study of adults admitted with influenza in a tertiary hospital during the 2017/2018 and 2018/2019 seasons. We calculated the concordance of the RAE-CMBD with the influenza epidemiological surveillance registry (gold standard), as well as the main parameters of internal and external validity. Logistic regression models were used for risk adjustment of in-hospital mortality and length of stay.

RESULTS

A total of 907 (97.74%) unique matches were achieved, with high inter-observer agreement (ƙ=0.828). The RAE-CMBD showed a 79.87% sensitivity, 99.72% specificity, 86.71% positive predictive value and 99.54% negative predictive value. The risk-adjusted mortality ratio of patients with influenza was lower than that of patients without influenza: 0.667 (0.53-0.82) vs. 1.008 (0.98-1.04) and the risk-adjusted length of stay ratio was higher: 1.15 (1.12-1.18) vs. 1.00 (0.996-1.001).

CONCLUSIONS

The RAE-CMBD is a valid source of information for the study of the impact of influenza on hospital care. The lower risk-adjusted mortality of patients admitted with influenza compared to other inpatients seems to point to the effectiveness of the main clinical and organisational measures adopted.

Attitudes, Perceptions and Practices of Influenza Vaccination in the Adult Population: Results of a Cross-Sectional Survey in Spain

In Spain, the 2021/22 influenza season overlapped with the sixth wave of the 2019 coronavirus disease pandemic (COVID-19). Influenza is a major public health problem associated with high morbidity and mortality. The objectives of this study were to determine the knowledge, perceptions and practices of influenza vaccination in the Spanish population, coinciding with the COVID-19 pandemic, with special attention paid to people over 65 years of age. A cross-sectional study was carried out by conducting 2211 telephone interviews. It was observed that 81.6% of people ≥ 65 years were vaccinated annually or with some frequency compared to 35.5% of those under 65 years (p < 0.001). Fifty percent of Spaniards showed an intention to be vaccinated in the 2021/22 campaign, during the SARS-CoV2 pandemic. In the case of people ≥ 65 years old, this figure was 83% compared to 42% of those under 65 years old (p < 0.001). Significant predictors of intention to be vaccinated were age of 65 years or older (OR 1.8, 95% CI 1.3-2.5), female sex (OR 1.9, 95% CI 1.5-2.4), belonging to risk groups (OR 2.2, 95% CI 1.6-3.1) and having been previously vaccinated (OR 29.7, 95% CI 22.5-39.2). The main reasons for deciding to be vaccinated were the need to be protected against the virus and to be vaccinated annually. On the other hand, lack of recommendation and considering the influenza vaccine as not necessary were the main reasons for not getting vaccinated. In addition, health personnel stood out as the main source of information (32.9%) compared to traditional media (26.9%) and public administration (12.3%). This study aimed to assess and analyse the factors influencing willingness to receive influenza vaccines in the COVID-19 era among Spanish adults, as well as the main information channels and strategies to encourage vaccination.

Influenza complications: Reporting cardiac events through a hospital surveillance system

BACKGROUND AND AIMS

The aim of this study was to determine the complications of influenza in all adults hospitalized with this disease and, specifically, to analyze the characteristics of post-infection cardiovascular events.

METHODS

This work is observational descriptive study of adults hospitalized with influenza during the 2017-2018 and 2018-2019 seasons using the specific registry of a tertiary hospital. The complications analyzed were pneumonia, multiple organ dysfunction syndrome, septic shock, acute respiratory distress syndrome, and cardiac events.

RESULTS

A total of 928 adults with influenza required hospitalization and 303 (32.7%) presented with one or more complications. A post-influenza cardiac event occurred in 2.5% of patients; they had a higher probability of ICU admission and higher mortality. Influenza vaccination was a protective factor for cardiac events (OR 0.32; 95%CI 0.13-0.83).

CONCLUSIONS

Influenza can lead to important complications in hospitalized patients. The high mortality rate associated with post-infection cardiac events means that preventive measures, including annual influenza vaccination, need to be emphasized.

Putative Secondary Structure at 5’UTR as a Potential Antiviral Target against SARS-CoV-2

SARS-CoV-2 is an enveloped positive-sense single-stranded RNA coronavirus that causes COVID-19, of which the current outbreak has resulted in a high number of cases and fatalities throughout the world, even vaccine doses are being administered. The aim of this work was to scan the SARS-CoV-2 genome in search for therapeutic targets. We found a sequence in the 5’UTR (NC\_045512:74-130), consisting of a typical heptamer next to a structured region that may cause ribosomal frameshifting. The potential biological value of this region is relevant through its low similarity with other viruses, including coronaviruses related to SARS-CoV, and its high sequence conservation within multiple SARSCoV-2 isolates. We have predicted the secondary structure of the region by means of different bioinformatic tools. We have suggested a most probable secondary structure to proceed with a 3D reconstruction of the structured segment. Finally, we carried out virtual docking on the 3D structure to look for a binding site and then for drug ligands from a database of lead compounds. Several molecules that could be probably administered as oral drugs show promising binding affinity within the structured region, and so it could be possible interfere its potential regulatory role.

[Choice of influenza vaccine in people over 65 years old. Analysis of reports from international vaccination advisory committees]

OBJECTIVE

Annual recommendations on influenza vaccine use in different countries are developed by influenza-specific working groups within their Immunization Advisory Committees. Adults aged 65 years and over are included in the groups for which vaccination against influenza is particularly recommended due to the morbidity associated. A variety of influenza vaccines are available, some of which boosted immunity, are licensed for use only in this specific age group, where the immune response to traditional influenza vaccines may be suboptimal. We analyze the main annual recommendations on the use of the influenza vaccine issued by advisory committees on immunization for the population over 65 years of age.

METHODS

The latest influenza vaccination guidelines have been selected and the recommendations for people over 65 years of age published by the main vaccination advisory committees have been reviewed.

RESULTS

The UK Advisory Committee (JCVI) recommends the use of Quadruvalent Inactivated Influenza Vaccine with Adjuvant (aQIV) or High Dose Quadrivalent Inactivated Influenza Vaccine (QIV-HD). The US committee (ACIP) does not express a preference for any type of vaccine. The Australian committee (ATAGI) preferably recommends adjuvanted influenza vaccine. The advisory committees of Canada and Germany (NACI, STIKO) and the European Center for Disease Control (Ecdc) recommend using any of the age-appropriate flu vaccines available, although they bet on the The UK Advisory Committee (JCVI) recommends the use of Quadruvalent Inactivated Influenza Vaccine with Adjuvant (aQIV) or High Dose Quadrivalent Inactivated Influenza Vaccine (QIV-HD). The US committee (ACIP) does not express a preference for any type of vaccine. The Australian committee (ATAGI) preferably recommends adjuvanted influenza vaccine. The advisory committees of Canada and Germany (NACI, STIKO) and the European Center for Disease Control (Ecdc) recommend using any of the age-appropriate flu vaccines available, although they bet on the use of inactivated quadrivalent flu vaccine high dose at the individual level for those over 65 years.use of inactivated quadrivalent flu vaccine high dose at the individual level for those over 65 years.

CONCLUSIONS

It is necessary further studies and improvement in their quality that analyze the different vaccines available and their comparability, although the use of reinforced immunity vaccines is generally recommended in the population over 65 years of age.

[Analysis of the demand for detection of SARSCoV-2 in a health area of Spain]

OBJECTIVE

Since the discovery of the SARS-CoV-2 virus, the polymerase chain reaction technique (RT-PCR) has become the fundamental method for diagnosing the disease in its acute phase. The objective is to describe the demand-based series of RT-PCR determinations received at a Microbiology Service at a third-level reference hospital for a health area for three months spanning from the onset of the epidemic by SARS-CoV-2.

METHODS

A retrospective analysis of the total of the RT-PCR requested in the Microbiology Service analyzed from 02/25/2020 to 05/26/2020 (90 days) has been carried out. They have been grouped by epidemiological weeks and by the petitioner service. A descriptive analysis was carried out by age, gender and number of requests for each patient. In the tests carried out, a confidence level of 95% (p <0.05) was considered significant.

RESULTS

A total of 27,106 requests was received corresponding to 22,037 patients. Median age 53.7 (RIC 40.9-71.7) years, women: 61.3%. Proportion of patients with any positive RT-PCR: 14%. Of the total requests for RT-PCR, positive 3,710. Week 13 had the highest diagnosis performance (39.0%). The primary care has been the service thar has made the most requests (15,953). Patients with 3 or more RT-PCR: 565, of them, 19 patients had a positive result after previously having a negative one.

CONCLUSIONS

Requests have been increasing depending on the evolution of the epidemic. The RT-PCR has a high diagnostic performance in the phases of highest contagiousness and / or transmissibility of the virus.

Occurrence of Hepatitis E Virus in Pigs and Pork Cuts and Organs at the Time of Slaughter, Spain, 2017

Zoonotic hepatitis E, mainly caused by hepatitis E virus (HEV) genotype (gt) 3, is a foodborne disease that has emerged in Europe in recent decades. The main animal reservoir for genotype 3 is domestic pigs. Pig liver and liver derivates are considered the major risk products, and studies focused on the presence of HEV in pig muscles are scarce. The objective of the present study was to evaluate the presence of HEV in different organs and tissues of 45 apparently healthy pigs from nine Spanish slaughterhouses (50% national production) that could enter into the food supply chain. Anti-HEV antibodies were evaluated in serum by an ELISA test. Ten samples from each animal were analyzed for the presence of HEV RNA by reverse transcription real-time PCR (RT-qPCR). The overall seroprevalence obtained was 73.3% (33/45). From the 450 samples analyzed, a total of 26 RT-qPCR positive samples were identified in the liver (7/45), feces (6/45), kidney (5/45), heart (4/45), serum (3/45), and diaphragm (1/45). This is the first report on detection of HEV RNA in kidney and heart samples of naturally infected pigs. HEV RNA detection was negative for rib, bacon, lean ham, and loin samples. These findings indicate that pig meat could be considered as a low risk material for foodborne HEV infection.

[Episodes of nontyphoidal salmonellosis in adult patients of the Valladolid West Area in 2017: Evaluation of the suitability of the microbiological culture request and the prescribed treatment]

OBJECTIVE

Gastroenteritic salmonellosis is still the second cause diagnosed of infectious diarrhea, most of these clinical pictures are mild and self-limited and therefore the use of antibiotics is limited to few cases. The aim of the study was to describe the episodes of diarrhea caused by Salmonella enterica subsp. enterica, assessing the suitability of the request and the use of antibiotics according to the criteria included in the methodology.

METHODS

A retrospective, descriptive, observational study was conducted, collecting data from the clinical history.

RESULTS

A total of 122 episodes were included. The reason for consultation was diarrhea, which generated a greater demand in the Hospital Emergency Services (42.6%). The most frequent serotypes isolated were Enteritidis (53.3%), and Typhimurium (40.2%). The adequate request of the stool was 90.2%. Antibiotic was prescribed in 64.6% (79) of the episodes, most patients under 65 years (58 episodes), the average age was 48.43 years. They were treated mainly with ciprofloxacin and azithromycin, in 57 and 14 episodes, respectively. The average duration of antibiotic treatment was 6 days. There was an adequate use of antibiotics in 49.1% of episodes. When the origin of the request was the Hospital Emergency Service, it was inadequate in 63.5% (33) of them. It was inadequate in 60.0% (39) of episodes when ser. Enteritidis was isolated. Almost half, 48.85% (42) of the 58 episodes in which antibiotics were prescribed among those under 65 (86), were treated without being indicated.

CONCLUSIONS

Training actions should be implemented focused on optimizing the management of antibiotics in this entity.

[Monophasic Salmonella Typhimurium outbreak due to the consumption of roast pork meat]

This report presents an outbreak of monophasic Salmonella enteric serovar Typhimurium fagotipe 4, 5, 12: i:-, in a motorcycle concentration in Valladolid. Information was collected to one hundred and twelve affected from seven Spanish Autonomous Communities. The epidemiological investigation associated the outbreak with the consumption of roast pork with sauce sandwiches sold at a street market in that event.

Antifungal treatment with echinocandins: a 10-year clinical experience

OBJECTIVE

The number of studies evaluating the use of echinocandins, whether or not its indication meets international guidelines, in clinical practice is limited. The objective of the present study was to determine the use of echinocandins in a tertiary Spanish hospital in 10 years of clinical practice, and to evaluate its impact on prognosis.

METHODS

This retrospective study involved adult nonneutropenic ill patients with suspicion of fungal invasion who started treatment with echinocandins between 2006 and 2015.

RESULTS

The number of patients treated with echinocandins was 153, and candidemia was detected thereafter in 25.5%. Factors associated with in-hospital mortality in patients receiving echinocandins were: sex male, septic shock, Charlson comorbidity index, and total stay at the hospital. In-hospital mortality after 7, 30 and 90 days was 13.7%, 24.8%, and 56.8%, respectively. From patients receiving echinocandins, 98 did no show multifocal colonization, 50 had Candida score <2.5, and 49 did not meet Ostrosky-Zeichner prediction rule. A total of 19 patients did not show any of these 3 potential risk factors for candidemia.

CONCLUSIONS

The use of echinocandins in 10 years of clinical practice in our tertiary hospital has been performed according to international guidelines; however, candidemia was only diagnosed thereafter in only 25.5% of cases. Furthermore, according to our results, the adequate use of echinocandins seems not to be associated with reduced mortality rates. Further studies, involving a large cohort of patients and more hospitals, are required to corroborate these results.

[A descriptive study of Hafnia alvei isolated from stool samples: an approach to its clinical assessment]

OBJECTIVE

The importance in human diarrhoeal disease of Hafnia alvei is unclear. The objective of the study was to describe the population which was isolated H. alvei in stool cultures and the therapeutic management of these cases in our Health Area.

METHODS

A descriptive retrospective study was carried out in 2014 and 2015. Epidemiological, clinical, treatment and evolution variables were collected in the computerized clinical history.

RESULTS

A collection of 7,290 stool specimens were processed, 3,321 in 2014 and 3,969 in 2015, of which 58 (1.7%) and 53 (1.3%) were positive for H. alvei, respectively. A 60.4% of samples were isolated in women. The mean age was 38.68 years. A 68.5% of samples were from primary care. In 71.2% there was related clinic, diarrhoea in 57.7%. In 75.7% of the cases there was not associated underlying disease. A 43.2% of the cases received treatment. A 66.7% of treated patients came from Primary Care. The mean duration of treatment was 8 days. The evolution was favourable in 85.4% of the cases treated. All strains were susceptible to ciprofloxacin and trimethoprim/sulfamethoxazole.

CONCLUSIONS

More evidence is needed to support H. alvei as a cause of gastroenteritis.

[Prevalence of human papillomavirus in Spanish women from a population screening program]

OBJECTIVE

The human papillomavirus (HPV), is necessary to cause a woman developing cervical cancer. The aim of the study was to estimate the prevalence of women with HPV infection, covered by the program of prevention and early detection of cervical cancer of Castile and León (Spain).

METHODS

Samples of women included in the screening program were analyzed. Including a total of 120,326 cervical swab samples, collected in the period from January 2012 to December 2014.

RESULTS

12,183 HPV positive samples were detected, representing a prevalence of 9.6 ‰, (IC 95% 9.5%-9.8%) in the female population. High-risk HPV were found in higher proportion that HPV low-risk genotypes. HPV prevalence correlates inversely with women age. Coinfections of multiple genotypes were found in one third of screened women population.

CONCLUSIONS

Data showed in this study are the first and wider Spanish results from a cervical cancer screening program population non opportunistic based on HPV detection. These results would serve as a reference for future prevalence studies and to evaluate the future impact of HPV vaccination campaigns.

Detection and identification of orthopoxviruses using a generic nested PCR followed by sequencing

Some orthopoxviruses are considered to be potential biological weapons. After the smallpox eradication campaign ended, routine vaccination was stopped around the world. Consequently, a significant portion of the population is now completely unprotected from infection by variola virus and related orthopoxviruses. Some of the symptoms associated with non-variola infections can be similar to smallpox, causing alert and panic situations. These infections should be considered as real public health concerns, so suitable tools for their differential diagnosis are needed. This study aims to devise a simple and easy-to-perform method that is able to detect and identify any orthopoxvirus that might cause infection in humans. In addition, the similarity of the different genes in the genomes of several species of orthopoxviruses is investigated, and orthopoxvirus-universal primer pairs in the tumour necrosis factor receptor II homologue gene are designed, taking full account of nucleotide similarity. A strategy is devised for their sensitive, rapid and cost-effective detection and identification, based on a nested PCR followed by sequencing. The efficacy of the method is tested with samples sent by the European Network of Imported Viral Diseases as part of two external quality control assays. All human orthopoxviruses assayed were detected and identified.

Molecular epidemiology of enterovirus 71, coxsackievirus A16 and A6 associated with hand, foot and mouth disease in Spain

Hand, foot and mouth disease (HFMD) is a childhood illness frequently caused by genotypes belonging to the enterovirus A species, including coxsackievirus (CV)-A16 and enterovirus (EV)-71. Between 2010 and 2012, several outbreaks and sporadic cases of HFMD occurred in different regions of Spain. The objective of the present study was to describe the enterovirus epidemiology associated with HFMD in the country. A total of 80 patients with HFMD or atypical rash were included. Detection and typing of the enteroviruses were performed directly in clinical samples using molecular methods. Enteroviruses were detected in 53 of the patients (66%). CV-A6 was the most frequent genotype, followed by CV-A16 and EV-71, but other minority types were also identified. Interestingly, during almost all of 2010, CV-A16 was the only causative agent of HFMD but by the end of the year and during 2011, CV-A6 became predominant, while CV-A16 was not detected. In 2012, however, both CV-A6 and CV-A16 circulated. EV-71 was associated with HFMD symptoms only in three cases during 2012. All Spanish CV-A6 sequences segregated into one major genetic cluster together with other European and Asian strains isolated between 2008 and 2011, most forming a particular clade. Spanish EV-71 strains belonged to subgenogroup C2, as did most of the European sequences circulated. In conclusion, the recent increase of HFMD cases in Spain and other European countries has been due to a larger incidence of circulating species A enteroviruses, mainly CV-A6 and CV-A16, and the emergence of new genetic variants of these viruses.

Viral infections of the central nervous system in Spain: a prospective study

The aim of the study was to determine the incidence of viruses causing aseptic meningitis, meningoencephalitis, and encephalitis in Spain. This was a prospective study, in collaboration with 17 Spanish hospitals, including 581 cases (CSF from all and sera from 280): meningitis (340), meningoencephalitis (91), encephalitis (76), febrile syndrome (7), other neurological disorders (32), and 35 cases without clinical information. CSF were assayed by PCR for enterovirus (EV), herpesvirus (herpes simplex [HSV], varicella-zoster [VZV], cytomegalovirus [CMV], Epstein-Barr [EBV], and human herpes virus-6 [HHV-6]), mumps (MV), Toscana virus (TOSV), adenovirus (HAdV), lymphocytic choriomeningitis virus (LCMV), West Nile virus (WNV), and rabies. Serology was undertaken when methodology was available. Amongst meningitis cases, 57.1% were characterized; EV was the most frequent (76.8%), followed by VZV (10.3%) and HSV (3.1%; HSV-1: 1.6%; HSV-2: 1.0%, HSV non-typed: 0.5%). Cases due to CMV, EBV, HHV-6, MV, TOSV, HAdV, and LCMV were also detected. For meningoencephalitis, 40.7% of cases were diagnosed, HSV-1 (43.2%) and VZV (27.0%) being the most frequent agents, while cases associated with HSV-2, EV, CMV, MV, and LCMV were also detected. For encephalitis, 27.6% of cases were caused by HSV-1 (71.4%), VZV (19.1%), or EV (9.5%). Other positive neurological syndromes included cerebellitis (EV and HAdV), seizures (HSV), demyelinating disease (HSV-1 and HHV-6), myelopathy (VZV), and polyradiculoneuritis (HSV). No rabies or WNV cases were identified. EVs are the most frequent cause of meningitis, as is HSV for meningoencephalitis and encephalitis. A significant number of cases (42.9% meningitis, 59.3% meningoencephalitis, 72.4% encephalitis) still have no etiological diagnosis.

Development of tropical spastic paraparesis in human T-lymphotropic virus type 1 carriers is influenced by interleukin 28B gene polymorphisms

Interleukin 28B (IL28B) rs12979860 polymorphisms were examined in 41 individuals with human T-lymphotrophic virus type 1 (HTLV-1). The alleles CT/TT were more frequent in 12 individuals with HTLV-1-associated myelopathy/tropical spastic paraparesis than in 29 asymptomatic carriers (80% vs 20%; P = .03), and median HTLV-1 proviral load was greater in CT/TT than CC carriers (P = .01). Thus, IL28B testing and closer follow-up of HTLV-1 asymptomatic CT/TT carriers is warranted.

Trends in the prevalence and distribution of HTLV-1 and HTLV-2 infections in Spain

Background

Although most HTLV infections in Spain have been found in native intravenous drug users carrying HTLV-2, the large immigration flows from Latin America and Sub-Saharan Africa in recent years may have changed the prevalence and distribution of HTLV-1 and HTLV-2 infections, and hypothetically open the opportunity for introducing HTLV-3 or HTLV-4 in Spain. To assess the current seroprevalence of HTLV infection in Spain a national multicenter, cross-sectional, study was conducted in June 2009.

Results

A total of 6,460 consecutive outpatients attending 16 hospitals were examined. Overall, 12% were immigrants, and their main origin was Latin America (4.9%), Africa (3.6%) and other European countries (2.8%). Nine individuals were seroreactive for HTLV antibodies (overall prevalence, 0.14%). Evidence of HTLV-1 infection was confirmed by Western blot in 4 subjects (prevalence 0.06%) while HTLV-2 infection was found in 5 (prevalence 0.08%). Infection with HTLV types 1, 2, 3 and 4 was discarded by Western blot and specific PCR assays in another two specimens initially reactive in the enzyme immunoassay. All but one HTLV-1 cases were Latin-Americans while all persons with HTLV-2 infection were native Spaniards.

Conclusions

The overall prevalence of HTLV infections in Spain remains low, with no evidence of HTLV-3 or HTLV-4 infections so far.

Early natural killer cell counts in blood predict mortality in severe sepsis

Introduction

Host immunity should play a principal role in determining both the outcome and recovery of patients with sepsis that originated from a microbial infection. Quantification of the levels of key elements of the immune response could have a prognostic value in this disease.

Methods

In an attempt to evaluate the quantitative changes in the status of immunocompetence in severe sepsis over time and its potential influence on clinical outcome, we monitored the evolution of immunoglobulins (Igs) (IgG, IgA and IgM), complement factors (C3 and C4) and lymphocyte subsets (CD4+ T cells, CD8+ T cells, B cells (CD19+) and natural killer (NK) cells (CD3-CD16+CD56+)) in the blood of 50 patients with severe sepsis or septic shock at day 1, day 3 and day 10 following admission to the ICU.

Results

Twenty-one patients died, ten of whom died within the 72 hours following admission to the ICU. The most frequent cause of death (n = 12) was multiorgan dysfunction syndrome. At day 1, survivors showed significantly higher levels of IgG and C4 than those who ultimately died. On the contrary, NK cell levels were significantly higher in the patients who died. Survivors exhibited a progressive increase from day 1 to day 10 on most of the immunological parameters evaluated (IgG, IgA, IgM, C3, CD4+, CD8+ T cells and NK cells). Multivariate Cox regression analysis, including age, sex, APACHE II score, severe sepsis or septic shock status and each one of the immunological parameters showed that NK cell counts at day 1 were independently associated with increased risk of death at 28 days (hazard ratio = 3.34, 95% CI = 1.29 to 8.64; P = 0.013). Analysis of survival curves provided evidence that levels of NK cells at day 1 (> 83 cells/mm³) were associated with early mortality.

Conclusions

Our results demonstrate the prognostic role of NK cells in severe sepsis and provide evidence for a direct association of early counts of these cells in blood with mortality.

Direct association between pharyngeal viral secretion and host cytokine response in severe pandemic influenza

BACKGROUND

Severe disease caused by 2009 pandemic influenza A/H1N1virus is characterized by the presence of hypercytokinemia. The origin of the exacerbated cytokine response is unclear. As observed previously, uncontrolled influenza virus replication could strongly influence cytokine production. The objective of the present study was to evaluate the relationship between host cytokine responses and viral levels in pandemic influenza critically ill patients.

METHODS

Twenty three patients admitted to the ICU with primary viral pneumonia were included in this study. A quantitative PCR based method targeting the M1 influenza gene was developed to quantify pharyngeal viral load. In addition, by using a multiplex based assay, we systematically evaluated host cytokine responses to the viral infection at admission to the ICU. Correlation studies between cytokine levels and viral load were done by calculating the Spearman correlation coefficient.

RESULTS

Fifteen patients needed of intubation and ventilation, while eight did not need of mechanical ventilation during ICU hospitalization. Viral load in pharyngeal swabs was 300 fold higher in the group of patients with the worst respiratory condition at admission to the ICU. Pharyngeal viral load directly correlated with plasma levels of the pro-inflammatory cytokines IL-6, IL-12p70, IFN-γ, the chemotactic factors MIP-1β, GM-CSF, the angiogenic mediator VEGF and also of the immuno-modulatory cytokine IL-1ra (p < 0.05). Correlation studies demonstrated also the existence of a significant positive association between the levels of these mediators, evidencing that they are simultaneously regulated in response to the virus.

CONCLUSIONS

Severe respiratory disease caused by the 2009 pandemic influenza virus is characterized by the existence of a direct association between viral replication and host cytokine response, revealing a potential pathogenic link with the severe disease caused by other influenza subtypes such as H5N1.

Host response cytokine signatures in viral and nonviral acute exacerbations of chronic obstructive pulmonary disease

Viruses are strongly associated with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Interferon-inducible protein-10 has been recently described as a biomarker of human rhinovirus infection, but there are no reports on the role of other immune mediators in AECOPD of viral origin. As an attempt to evaluate the differences in the systemic immune mediators profiles between AECOPD patients with presence/absence of viral infection, we measured 27 cytokines, chemokines, and cellular growth factors in the plasma of 40 patients with AECOPD needing of hospitalization by using a Luminex-based assay. These patients were screened for the presence of 16 different respiratory viruses in pharyngeal swabs. Ten healthy controls were recruited for comparison purposes. Both the group of patients with an associated viral infection (n = 11) and those with no viral infection (n = 29) showed high levels of vascular endothelial growth factor, interleukin-13 (IL-13), and IL-2. On the other hand, viral infection in AECOPD induced a coordinated response of innate immunity chemokines (eotaxin, interferon-inducible protein-10, IL-8), Th1 cytokines (IL-12p70, IL-15), and the immunomodulatory IL-10. This profile corresponds to a typical antiviral response signature previously documented for other viral infections. The identification of early cytokine signatures associated with viral infection in AECOPD could contribute to design better treatment strategies for this disease.

[Variability in the sensitivity to tigecycline against Acinetobacter baumannii in different culture media]

INTRODUCTION

The tigecycline may represent a therapeutic alternative for the control of multiresistant A. baumannii, although there is no consensus regarding the cutoff points for sensitivity or variability of MIC as a function of culture medium used for the antibiogram against this microorganism. Therefore, our objective was to verify this variability, and propose the culture medium that comes closest to the standard method.

METHODS

We selected 41 strains of carbapenem-resistant A. baumannii. We analyzed the sensitivity to tigecycline in different culture media: Mueller Hinton agar Oxoid commercial (C-MH), Mueller Hinton fresh agar BD and Co., USA (F-MH) and ISO-sensitest fresh agar Oxoid, using the E-test and disk. The MICs were compared against those obtained using the technique standard of macrodilution.

RESULTS

The mean MIC and inhibition diameters obtained in the different culture media corresponded to 9.26 mg/L and 15.1 mm in diameter for MH-C, 1.71 mg/L and 22.7 mm for MH-F; 2.68 mg/L and 20.8 mm for ISO-sensitest. Half the MIC obtained by the standard method of dilution was 0.47 mg/L (SD =0.21), with values between 0.25 and 1 mg/L.

CONCLUSION

In the three growth media studied, MICs superior to the standard are observed, which is false to interpret resistance in many cases. However, the medium that comes closer more that of reference is the MH-F.

Th1 and Th17 hypercytokinemia as early host response signature in severe pandemic influenza

Introduction

Human host immune response following infection with the new variant of A/H1N1 pandemic influenza virus (nvH1N1) is poorly understood. We utilize here systemic cytokine and antibody levels in evaluating differences in early immune response in both mild and severe patients infected with nvH1N1.

Methods

We profiled 29 cytokines and chemokines and evaluated the haemagglutination inhibition activity as quantitative and qualitative measurements of host immune responses in serum obtained during the first five days after symptoms onset, in two cohorts of nvH1N1 infected patients. Severe patients required hospitalization (n = 20), due to respiratory insufficiency (10 of them were admitted to the intensive care unit), while mild patients had exclusively flu-like symptoms (n = 15). A group of healthy donors was included as control (n = 15). Differences in levels of mediators between groups were assessed by using the non parametric U-Mann Whitney test. Association between variables was determined by calculating the Spearman correlation coefficient. Viral load was performed in serum by using real-time PCR targeting the neuraminidase gene.

Results

Increased levels of innate-immunity mediators (IP-10, MCP-1, MIP-1β), and the absence of anti-nvH1N1 antibodies, characterized the early response to nvH1N1 infection in both hospitalized and mild patients. High systemic levels of type-II interferon (IFN-γ) and also of a group of mediators involved in the development of T-helper 17 (IL-8, IL-9, IL-17, IL-6) and T-helper 1 (TNF-α, IL-15, IL-12p70) responses were exclusively found in hospitalized patients. IL-15, IL-12p70, IL-6 constituted a hallmark of critical illness in our study. A significant inverse association was found between IL-6, IL-8 and PaO2 in critical patients.

Conclusions

While infection with the nvH1N1 induces a typical innate response in both mild and severe patients, severe disease with respiratory involvement is characterized by early secretion of Th17 and Th1 cytokines usually associated with cell mediated immunity but also commonly linked to the pathogenesis of autoimmune/inflammatory diseases. The exact role of Th1 and Th17 mediators in the evolution of nvH1N1 mild and severe disease merits further investigation as to the detrimental or beneficial role these cytokines play in severe illness.

Nasopharyngeal aspirate cytokine levels 1 yr after severe respiratory syncytial virus infection

Respiratory syncytial virus (RSV) infection is an important cause of recurrent wheezing in infants. Nevertheless, the link between RSV infection and wheezing has yet to be elucidated at the molecular level. Here, we present a preliminary study on the evolution of the immune response in the respiratory tract at long-term after RSV infection. Twenty-seven immune mediators were profiled in nasopharyngeal aspirates (NPAs) obtained from 20 children hospitalized due to a severe infection by RSV at discharge from hospital and again 1 yr later. The same mediators were profiled in parallel in NPAs from 12 healthy controls. In the year following discharge, 85% (17/20) of children of the RSV group suffered at least one episode of wheezing documented by the pediatrician. On the contrary, wheezing episodes were observed only in 25% (3/12) of children in the control group. While most of the mediators profiled returned to normal levels by 1 yr after discharge from hospital, RSV children showed a persistent nasal hyper-secretion of VEGF, G-CSF, IL-10, IL-6, IFN-gamma, IL-7 and IL-13. In previous works VEGF, IL-10 and IFN-gamma have been put in relation with the pathogenesis of post-virus induced asthma. G-CSF, IL-6, IL-7 and IL-13 are increased in respiratory and plasma samples of asthmatic patients. Here, we evidence for the first time a persistent elevation of these mediators as late as 1 yr after severe RSV disease resolution, reinforcing their possible implication in the pathogenesis of wheezing.

Viral Load in Spanish HIV patients: trends since the introduction of HAART

The aim of this study is to describe trends in the percentage of samples with undetectable HIV viral load in Spain after the implementation of HAART. A descriptive observational study of HIV-VL measurements carried out in the microbiology department of the Hospital Clínico Universitario de Valladolid (HCUV) was conducted over a 9-year period (1996-2004). Regarding the trend over the study period, the 30-39 years age group accounted for most of the samples, although the percentage decreased from 65.5% to 59.6% over the study period. In contrast, the 40-49 years group increased from 9.1% to 14.5%. The preponderance of men, with percentages above 70%, was observed during the whole period. Although the purpose of this treatment is to maintain undetectable viral loads, since 1999 more than 60% of nonfirst samples had detectable levels. Based on the results of the VL trend among HIV/AIDS patients observed in this study, a large number of patients maintain elevated detectable VL years after HAART was implemented. Although different factors may be the cause of this and should be delimited in future studies, the phenomenon observed demonstrates the usefulness of monitoring VL and analyzing its time trend to gain further knowledge about the therapeutic results and care of HIV patients as a whole, also serving as the basis for corrective measures.

Trend and seasonality of tuberculosis in Spain, 1996-2004

This study aimed to analyse the trend and seasonality of tuberculosis (TB) in Spain over the past decade. Weekly TB incidence was calculated using data from the National Surveillance Network for the period 1996-2004. Secular trends and seasonal components were estimated using time-series analysis (least-squares method and Fourier transformation). A decline in incidence was observed, from 23.4 cases per 100,000 population in 1997 to 15.1 in 2004, and an annual cycle peaking in June was detected. Time-series analyses are necessary for detecting changes in the epidemiological pattern of TB in Spain, and it should be the first step towards the development of a predictive model.