[Initial assessment of immigrant patients in primary care]

The clinical interview of immigrant patients requires cultural competence to ensure good understanding and correct communication, in addition to collecting specific information that differs from that of native patients, such as origin and migratory route or cultural identity. Screening for latent tuberculosis infection is recommended in certain cases and screening for other infections, both cosmopolitan with a higher prevalence in migrants (HIV, syphilis, hepatitis B and C) and imported (Chagas, intestinal parasites, strongyloidiasis, schistosomiasis), depending on origin. It is essential to check the vaccination status and complete the vaccination schedule, adapting it to the current calendar, prioritizing vaccines such as measles, rubella and poliomyelitis. We propose preventive activities to be carried out when traveling to countries of origin, due to their special characteristics and risks: general advice, exploring the risk of malaria, assessing specific vaccinations, advice regarding sexually transmitted infections and special considerations if they have chronic diseases; and addressing, if appropriate, the risks of female genital mutilation.

The MVA vector expressing the F protein of bovine respiratory syncytial virus is immunogenic in systemic and mucosal immunization routes

Bovine respiratory syncytial virus (BRSV) affects both beef and dairy cattle, reaching morbidity and mortality rates of 60-80% and 20%, respectively. The aim of this study was to obtain a recombinant MVA expressing the BRSV F protein (MVA-F) as a vaccine against BRSV and to evaluate the immune response induced by MVA-F after systemic immunization in homologous and heterologous vaccination (MVA-F alone or combined with a subunit vaccine), and after intranasal immunization of mice. MVA-F administered by intraperitoneal route in a homologous scheme elicited levels of neutralizing antibodies similar to those obtained with inactivated BRSV as well as better levels of IFN-γ secretion. In addition, nasal administration of MVA-F elicited local and systemic immunity with a Th1 profile. This study suggests that MVA-F is a good candidate for further evaluations combining intranasal and intramuscular routes, in order to induce local and systemic immune responses, to improve the vaccine efficacy against BRSV infection.

[Adaptation and validation of the MoVac-flu scale on motivation towards the flu vaccine]

OBJECTIVE

To translate, adapt and validate the psychometric properties of MoVac-flu scale in order to be used in Spanish.

METHOD

The present research was an analytical observational study of cross-cultural adaptation and validation into Spanish of the MoVac-flu scale. It has been carried out between the months of March and July 2022. The sample size was 142 people who were obtained by consecutive sampling. The processes used for the adaptation have been translation, validation by a committee of experts, back-translation and pilot test. For validation, the psychometric properties of reliability, internal consistency, appearance validity, content validity, utility and ceiling-floor effect have been verified.

RESULTS

The internal consistency of the MoVac-flu scale in its version translated into Spanish was high, showing a McDonald's ω of 0.914.

CONCLUSIONS

The MoVac-flu scale in Spanish allows to measure the degree of motivation towards vaccination against influenza in the adult population.

Lessons from SENCOVAC: A prospective study evaluating the response to SARS-CoV-2 vaccination in the CKD spectrum

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has negatively impacted on patients of the whole CKD spectrum, causing high rates of morbi-mortality. SARS-CoV-2 vaccines opened a new era, but patients with CKD (including kidney transplant, hemodialysis and peritoneal dialysis) were systematically excluded from pivotal clinical trials. The Spanish Society of Nephrology promoted the multicentric national SENCOVAC study aimed at assessing immunological responses after vaccination in patients with CKD. During the first year after vaccination, patients with non-dialysis CKD and those on hemodialysis and peritoneal dialysis presented good anti-Spike antibody responses to vaccination, especially after receiving the third and fourth doses. However, kidney transplant recipients presented suboptimal responses after any vaccination schedule (initial, third and fourth dose). Especially worrisome is the situation of a patients with a persistently negative humoral response that do not seroconvert after boosters. In this regard, monoclonal antibodies targeting SARS-CoV-2 have been approved for high-risk patients, although they may become obsolete as the viral genome evolves. The present report reviews the current status of SARS-CoV-2 vaccination in the CKD spectrum with emphasis on lessons learned from the SENCOVAC study. Predictors of humoral response, including vaccination schedules and types of vaccines, as well as the integration of vaccines, monoclonal antibodies and antiviral agents are discussed.

Old and new aspects of influenza

Influenza is a classic infectious disease that, through the continuous variation of the viruses that produce it, imposes new challenges that we must solve as quickly as possible. The COVID-19 pandemic has substantially modified the behavior of influenza and other respiratory viruses, and in the coming years we will have to coexist with a new pathogen that will probably interact with existing pathogens in a way that we cannot yet glimpse. However, knowledge prior to the pandemic allows us to focus on the aspects that must be modified to make influenza an acceptable challenge for the future. In this review, emphasis is placed on the most relevant aspects of epidemiology, disease burden, diagnosis, and vaccine prevention, and how scientific and clinical trends in these aspects flow from the previously known to future challenges.

Vaccination schedule for adolescents. Consensus of the AEV, CAV-AEP and SEMA

We present the consensus document on the immunization schedule for adolescents developed by 3 scientific societies: the Spanish Association of Pediatrics (AEP), through its Advisory Committee on Vaccines (CAV-AEP), the Spanish Society of Adolescent Medicine (SEMA) and the Spanish Association of Vaccinology (AEV). There are particularities in infectious disease during adolescence, such as an increased susceptibility to pertussis, poorer outcomes of chickenpox, mumps and hepatitis A, a high incidence of sexually transmitted infections or increased prevalence of meningococcal carriage. The document analyses the schedule for adolescents in the context of vaccination policy overall. It contemplates the vaccines to be included in the immunization schedule for healthy adolescents: against invasive meningococcal disease (tetravalent ACWY and B), against human papillomavirus (which should be gender-neutral), against pertussis, against influenza and against SARS-CoV-2 (in unvaccinated individuals and at-risk groups). It is worth noting that the 4CMenB vaccine appears to confer some protection against gonococcal infection, which would be a considerable added value for adolescents. The vaccination of adolescents belonging to risk groups or travelling abroad also needs to be contemplated, as is the case in any other age group. Vaccination against hepatitis A, which is included in the routine immunization schedule of Catalonia, Ceuta and Melilla from the second year of life, should also be considered a priority in adolescents traveling to endemic areas.

Vaccines against monkeypox

The monkeypox virus is a virus that has 90% genomic homology with the human (smallpox), but it is naturally transmitted between different wild animal reservoirs and is considered a zoonosis. Throughout the 20th century, different vaccines based on the vaccinia poxvirus were developed and used for vaccination against smallpox. After the eradication of smallpox, these vaccines were no longer used. Current vaccines against monkeypox virus are classified by the WHO as replicative (ACAM2000), minimally replicative (LC16m8) and non-replicative (MVA-BN), the latter being the one currently used. The 2022 extra-African monkeypox virus epidemic has highlighted the lack of vaccines with proven efficacy and low reactogenicity. It is considered that the use of this vaccine in the current outbreak may play a role in the prevention or attenuation of the disease as pre-exposure prophylaxis in close contacts of confirmed cases.

Evaluation of persistent COVID and SARS-CoV-2 reinfection in a cohort of patients on the island of Gran Canaria, Spain

INTRODUCTION

This study analyzed the impact of patients' age, sex, vaccination, immunosuppressive treatment, and previous comorbidities on the risk of developing persistent COVID-19 or SARS-CoV-2 virus reinfection.

METHOD

Population-based observational retrospective study of a cohort of 110,726 patients aged 12 years or older, who were diagnosed with COVID-19 between June 1st, 2021 and February 28th, 2022 in the island of Gran Canaria.

RESULTS

340 patients suffered reinfection. The combination of advanced age, female sex and lack of complete or incomplete vaccination against COVID-19 was strongly predictive of reinfection (p<0.05). In the 188 patients who developed persistent COVID-19, the persistence of symptoms was more frequent in adult patients, women, and patients with a diagnosis of asthma. Complete vaccination was associated with a lower risk of reinfection ([OR] 0.05, 95%CI 0.04-0.07; p<0.05) and of developing persistent COVID-19 ([OR] 0.07, 95%CI 0.05-0.10; p<0.05). None of the patients with reinfection or persistent COVID-19 died during the period of the study.

CONCLUSIONS

This study confirmed the link between age, sex, asthma and risk of persistent COVID-19. It was not possible to define the patient's comorbidities as a factor that influences the development of reinfection, but its association with age, sex, type of vaccine and hypertension was demonstrated. Higher vaccination coverage was associated with a lower risk of persistent COVID-19 or SARS-CoV-2 reinfection.

Importance of the SARS-CoV-2 genome and spike protein in the immunopathogenesis of COVID-19 and in the efficacy of vaccines

Coronavirus (CoV) infections cause respiratory and enteric diseases with clinical manifestations ranging from faint to severe, even lead to death of patients. High connectivity between nations and infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), represent a global health problem as the coronavirus disease 19 (COVID-19). This CoV-2 that cause SARS, which appeared in Wuhan, China, in December 2019 originated COVID-19 and declared as pandemic a few months posterior its appearance. In this review, the genomic and spike protein characteristics of SARS-CoV-2, the role of SARS-CoV-2 in the COVID-19 pathogenesis, cytokine storm, the role of cytotoxic T and B cells against SARS-CoV-2, as well as the vaccines efficacy (taking into account mutations in the spike protein) are described.

Prevalence of SARS-CoV-2 antibodies in cancer patients and healthcare workers vaccinated with two doses of BNT162b2 or AZD122. A propensity analysis

BACKGROUND

Vaccination is the most effective intervention for reducing the burden of SARS-CoV-2-related disease; however, gaps in knowledge regarding cancer patients (CPs) immune response persist.

OBJECTIVES

To evaluate the humoral response (anti-S antibodies) in CPs and healthcare workers (HCWs) vaccinated with two doses of BNT162b2 or AZD122 vaccines.

MATERIAL AND METHODS

Polyspecific anti-SARS-CoV-2 spike protein (anti-S) antibodies were quantified, and a 1:1 propensity score was used to balance baseline characteristics. Multiple logistic regressions were carried out to evaluate the effect of humoral response-related variables.

RESULTS

One-hundred and twenty-seven CPs (22%) and 439 HCWs (78%) were included. Both populations developed anti-S antibodies in response to vaccination. The mRNA-based vaccine (BNT162b2) was associated with higher odds of having anti-S antibody titers ≥ 1,000 U/mL, while active cancer was related to a lower probability of developing high antibody titers.

CONCLUSIONS

The BNT162b2 vaccine was associated with a higher humoral response. It is necessary for more information and vaccination strategies to be available for immunosuppressed patients in order to select the best biologics for this population based on individual characteristics.

Development of vaccines for Chagas disease (CRUZIVAX): stakeholders' preferences and potential impacts on healthcare

A vaccine for Chagas disease does not currently exist. This study aims to inform the development of two vaccines for the prevention and treatment of Trypanosoma cruzi infection, and guide their pre-clinical phase up to clinical phase I. The three main objectives are: 1) to explore patients' and policy makers' preferences on the candidate vaccines in Argentina and Spain; 2) to investigate health-related quality of life of patients affected by Chagas disease; and 3) to assess the potential health provider savings associated with the vaccines, in terms of resource use and health care costs. Discrete choice experiments will be employed to estimate and characterize the theoretical demand for the vaccines and investigate patients' and policy makers' preferences. Health-related quality of life will be assessed using the EQ-5D-3L questionnaire. Resources use and costs associated with Chagas disease will be investigated using information from the databases of the Hospital Clínic of Barcelona.

[Towards COVID-19 control through vaccination: obstacles, challenges and opportunities. SESPAS Report 2022]

En España se inició el programa de vacunación en un contexto de alta transmisión y baja disponibilidad de vacunas. El objetivo de este artículo es revisar el programa de vacunación frente a la COVID-19 (3-3-2022) y valorar los obstáculos, los desafíos y las oportunidades que plantea el control de esta enfermedad. Se dispone actualmente de cinco vacunas: dos basadas en la tecnología ARNm (Comirnaty® y Spikevax®), dos basadas en un vector no replicativo (Vaxzevria® y Janssen) y una basada en la subunidad S (Novavax®). Las autoridades sanitarias han desarrollado estrategias de vacunación priorizando la prevención de hospitalizaciones y defunciones. En marzo de 2022 se superó el 90% de la población diana con vacunación completa y el 95% de cobertura en mayores de 50 años. El nuevo reto es conseguir coberturas similares para una tercera dosis. La vacunación en la infancia y la adolescencia se ha convertido en una prioridad por las implicaciones educativas y sociales que comporta la COVID-19. Se deberán renovar las estrategias comunicativas y eliminar las barreras de acceso para conseguir buenas coberturas. En España se han publicado estudios que muestran una alta efectividad de la vacunación. La principal estrategia para el control de la pandemia y para recuperar la actividad social es la vacunación, pero todo indica que serán necesarios niveles muy altos de cobertura vacunal y seguir con medidas no farmacológicas. En un mundo globalizado, el control de la COVID-19 solo se alcanzará con una estrategia global coordinada y el apoyo a la vacunación en los países con pocos recursos.

Main changes in the "COVID-19 in paediatrics" clinical practice guideline

We present a summary of the main modifications to the “COVID-19 in Paediatrics” clinical practice guideline made from its initial version, published in 2021, and the version published in 2022. The document was developed following the structured steps of evidence-based medicine and applying the GRADE system to synthesize the evidence, assess its quality and, when appropriate, issue graded recommendations (based on the quality of the evidence, values and preferences, the balance between benefits, risks and costs, equity and feasibility). This update also includes the modifications proposed by external reviewers.

We summarised the main modifications in the following sections: epidemiology, clinical features, diagnosis, prevention, treatment and vaccines. In relation to the body of knowledge achieved in the first year of the pandemic, the literature published in the second year contributed additional data, but without substantial modifications in many the areas. The main changes took place in the field of vaccine research. This update was completed in December 2021, coinciding with the emergence of infections by the omicron variant, so the document will need to be updated in the future.

Acute hepatitis B among HIV positive persons: A two-decade review of cases from a Spanish cohort

PURPOSE

To review the incidence and characteristics of acute hepatitis B (AHB) in a large cohort of HIV infected persons from a low prevalence region during the last two decades.

METHODS

Retrospective review of an HIV Cohort from a single reference centre in Madrid, Spain, between 2000 and 2018. AHB was diagnosed in persons with newly acquired HBAgS and acute hepatitis with positive IgM anti-HBc.

RESULTS

Out of 5443 HIV+ patients in our cohort (3098 anti-HBc negative), 18 developed AHB from 2000 to 2018. The global incidence was 0.02 (0.01-0.04) per 100 patient-year in the entire population and 0.06 (0.01-0.1) per 100 patient-year in the anti-HBc negative population. A statistically significant decrease in AHB incidence was observed during these years (β=-0.006; p=0.047). All 18 patients diagnosed with AHB were men, the majority (16) occurred in men who have sex with men. AHB was observed in 4 persons previously unresponsive to vaccination. Regarding antiretroviral treatment (ART), 15 were not receiving ART, two persons were on ART with any HBV active drugs and one person had lamivudine in the regimen. Two persons (11%) developed chronic hepatitis B. There were no cases of fulminant hepatitis.

CONCLUSION

The incidence of AHB in HIV positive persons in our cohort was low and shows a progressive decline in the last 20 years. Cases occurred in persons not protected against VHB: not vaccinated or non-responders to vaccine that were not receiving tenofovir.

COVID-19: Critical appraisal of the evidence

We present the summary of a critical appraisal document of the available evidence on COVID-19, developed with a clinical practice guide format following GRADE methodology. The document tries to provide answers to a series of structured clinical questions, with an explicit definition of the population, intervention / exposure, comparison and outcome, and a rating of the clinical relevance of the outcome measures. We conducted a systematic review of the literature to answer the questions, grouped into six chapters: epidemiology, clinical practice, diagnosis, treatment, prevention, and vaccination. We assessed the risk of bias of the selected studies with standard instruments (RoB-2, ROBINS-I, QUADAS and Newcastle-Ottawa). We constructed evidence tables and, when necessary and possible, meta-analysis of the of the most relevant outcome measures. We followed the GRADE system to synthesise the evidence, assessing its quality, and, when appropriate, giving recommendations, rated according to the quality of the evidence, the values and preferences, the balance between benefits, risks and costs, equity and feasibility.

[Cognitive, ethical, social and political aspects in risk assessment: regarding vaccines against SARS-CoV-2]

Risk is a concept that is usually evaluated by scientists and public health experts by comparing probabilities. However, this ethical utilitarian perspective, which considers that the best decision is the one that has less probability of harm than of benefit, does not consider normative aspects based on other ethical perspectives. Interpreting the origin of public controversies arising from people's reactions to the small risks of attenuated SARS-CoV-2 vaccines and evaluating the responses of public institutions requires an understanding of both the cognitive aspects that introduce systematic biases in the assessment of probabilities and the sociological, ethical, and political framework that contextualizes risk management in modern societies.

FACME multidisciplinary working group on the management of cerebral venous sinus thrombosis associated with COVID-19 vaccination. Diagnostic and treatment recommendations from the FACME ad-hoc expert working group on the management of cerebral venous sinus thrombosis associated with COVID-19 vaccination

INTRODUCTION

Cases of cerebral venous sinus thrombosis have been reported in individuals vaccinated against COVID-19 with non-replicating adenoviral vector vaccines. We issue our recommendations on the diagnosis and management of patients presenting this complication.

METHODS

The multidisciplinary working group, led by the Spanish Federation of Medical and Scientific Associations (FACME) and including representatives of several scientific societies, reviewed the available evidence from the literature and reports of the European Medicines Agency. We establish a definition for suspected cases and issue diagnostic and treatment recommendations regarding vaccine-induced immune thrombotic thrombocytopaenia.

RESULTS

We define suspected cases as those cases of cerebral venous sinus thrombosis occurring between 3 and 21 days after the administration of non-replicating adenoviral vector vaccines, in patients with a platelet count below 150 000/μL or presenting a decrease of 50% with respect to the previous value. Findings suggestive of vaccine-induced immune thrombotic thrombocytopaenia include the presence of antibodies to platelet factor 4, D-dimer levels 4 times greater than the upper limit of normal, and unexplained thrombosis. The recommended treatment includes intravenous administration of non-specific human immunoglobulin or alternatively plasmapheresis, avoiding the use of heparin, instead employing argatroban, bivalirudin, fondaparinux, rivaroxaban, or apixaban for anticoagulation, and avoiding platelet transfusion.

CONCLUSIONS

Non-replicating adenoviral vector vaccines may be associated with cerebral venous sinus thrombosis with thrombocytopaenia; it is important to treat the dysimmune phenomenon and the cerebral venous sinus thrombosis.

SARS-CoV-2 Vaccines and the Skin

Vaccines against the severe acute respiratory coronavirus 2, which are the first to be used in humans against any coronavirus, were developed and produced in record time. Dermatologic adverse effects appeared during clinical trials and have also been described in the population since approval. Just as descriptions and categorization of skin manifestations of the coronavirus disease 2019 proved important for understanding the disease itself, characterizing the effects of vaccines may also further that goal. This paper reviews the properties of the different types of vaccines currently available and under development and describes how they interact with the immune system and the clinical signs they may cause. We focus on dermatologic adverse effects reported to date and recommendations for managing them.

Grupo de trabajo multidisciplinar de FACME sobre el manejo de la trombosis venosa cerebral relacionada con la vacunación frente a COVID-19. Diagnostic and treatment recommendations from the FACME ad-hoc expert working group on the management of cerebral venous sinus thrombosis associated with COVID-19 vaccination

Introducción

Se han reportado casos de trombosis venosas cerebrales en personas vacunadas frente a COVID-19 con vacunas vectorizadas con adenovirus no replicantes. Aportamos recomendaciones sobre el diagnóstico y manejo de pacientes con esta complicación.

Método

El grupo de trabajo multidisciplinar, liderado por la Federación de Asociaciones Científico Médicas Españolas y representado por distintas sociedades científicas, revisó la evidencia disponible publicada en la literatura y en los informes de la Agencia Europea de Medicamentos. Se estableció una definición de caso sospechoso y recomendaciones diagnóstico-terapéuticas de la trombocitopenia trombótica inducida por la vacunación.

Resultados

Se considera caso sospechoso aquella trombosis venosa cerebral ocurrida entre 3 y 21 días tras la administración de vacunas no replicantes de adenovirus que presenten un valor de plaquetas inferior a 150.000 plaquetas por μL o un descenso del 50% respecto de la cifra previa. Los datos indicativos de trombocitopenia trombótica inducida por la vacunación incluyen la presencia de anticuerpos antifactor plaquetario tipo 4, la elevación de dímero-D 4 veces por encima del límite superior de la normalidad o la ausencia de justificación de la trombosis. En su tratamiento, se recomienda administrar inmunoglobulina humana inespecífica intravenosa o realizar plasmaféresis en su defecto, evitar el uso de heparina, empleando como anticoagulantes argatroban, bivalirudina, fondaparinux, rivaroxabán o apixabán, y evitar la transfusión de plaquetas.

Conclusiones

Las vacunas de vectores no replicantes de adenovirus pueden asociarse a trombosis venosas cerebrales con trombocitopenia, en cuyo manejo es importante el tratamiento del fenómeno disinmune y de la trombosis venosa cerebral.

Risk of infection associated with Janus Kinase (JAK) inhibitors and biological therapies in inflammatory intestinal disease and rheumatoid arthritis. Prevention strategies

Patients with certain immune-mediated inflammatory diseases, such as rheumatoid arthritis (RA) and inflammatory bowel disease (IBD), have an increased risk of severe infectious diseases than the general population, which are mainly associated with the immunosuppressive treatments that they receive. These treatments act on the immune system through different mechanisms, causing different degrees of immunosuppression and a variable risk depending on whether the pathogen is a virus, bacteria or fungus. This article reviews the most relevant literature on the subject, which was selected and discussed by a panel of experts. The aim of this article is to review the risk of infections in patients with IBD and RA, and the potential preventive measures.

[Immunisation schedule of the Pediatric Spanish Association: 2021 recommendations]

The CAV-AEP annually publishes the immunisation schedule considered optimal for all children and adolescent resident in Spain, taking into account the available evidence. The 2+1 schedule is recommended (2, 4, and 11 months) with hexavalent vaccines (DTPa-VPI-Hib-HB) and with 13-valent pneumococcal conjugate.A 6-year booster is recommended, preferably with DTPa (if available), with a dose of polio for those who received 2+1 schemes, as well as vaccination with Tdpa in adolescents and in each pregnancy, preferably between 27 and 32 weeks. Rotavirus vaccine should be systematic for all infants. Meningococcal B vaccine, with a 2+1 schedule, should be included in routine calendar. In addition to the inclusion of the conjugated tetravalent meningococcal vaccine (MenACWY) at 12 years of age with catch up to 18 years, inclusive, the CAV recommends this vaccine to be also included at 12 months of age, replacing MenC. Likewise, it is recommended in those over 6 weeks of age with risk factors or who travel to countries with a high incidence of these serogroups. Two-dose schedules for triple viral (12 months and 3-4 years) and varicella (15 months and 3-4 years) will be used. The second dose could be applied as a tetraviral vaccine. Universal systematic vaccination against HPV is recommended, regardless of gender, preferably at 12 years, and greater effort should be made to improve coverage. The 9 genotype extends coverage for both genders.

Are patients with inflammatory bowel disease receiving adequate immunisation?

INTRODUCTION

Inflammatory Bowel Disease (IBD) treatment may increase the risk of infections. Vaccines are part of the comprehensive IBD patient care. The aim of this study was to describe indications and adherence of immunizations in IBD and identify possible associated factors.

METHODS

A cross-sectional, analytic study was conducted in patients from an IBD Program of a tertiary center in Chile, between April - June 2019. Patients were asked to answer a vaccine survey and information also was obtained from the National Immunization Registry. Descriptive and association statistic were used (χ²; p<0.05).

RESULTS

A total of 243 patients were included (148 ulcerative colitis (UC), 86 Crohn's disease (CD) and 9 non-classifiable IBD). Only six patients (2%) of IBD patients received a complete immunization schedule. The highest vaccine rates were against influenza (67%), hepatitis B virus (40%), 13-valent pneumococcal (34%) and 23-polysaccharide pneumococcal (16%). The influenza vaccine rate has significantly increased, reaching 67% in 2019. The survey showed that 23% of patients have not been immunized with any vaccine, mainly due to lack of time, lack of medical prescription and high cost.

CONCLUSIONS

In this cohort, although vaccination rates are higher than previously reported, adherence to IBD immunization program would be improved, being considered since diagnosis by the multidisciplinary team.

Acute hepatitis B among HIV positive persons: A two-decade review of cases from a Spanish cohort

PURPOSE

To review the incidence and characteristics of acute hepatitis B (AHB) in a large cohort of HIV infected persons from a low prevalence region during the last two decades.

METHODS

Retrospective review of an HIV Cohort from a single reference centre in Madrid, Spain, between 2000 and 2018. AHB was diagnosed in persons with newly acquired HBAgS and acute hepatitis with positive IgM anti-HBc.

RESULTS

Out of 5443 HIV+ patients in our cohort (3098 anti-HBc negative), 18 developed AHB from 2000 to 2018. The global incidence was 0.02 (0.01-0.04) per 100 patient-year in the entire population and 0.06 (0.01-0.1) per 100 patient-year in the anti-HBc negative population. A statistically significant decrease in AHB incidence was observed during these years (β=-0.006; p=0.047). All 18 patients diagnosed with AHB were men, the majority (16) occurred in men who have sex with men. AHB was observed in 4 persons previously unresponsive to vaccination. Regarding antiretroviral treatment (ART), 15 were not receiving ART, two persons were on ART with any HBV active drugs and one person had lamivudine in the regimen. Two persons (11%) developed chronic hepatitis B. There were no cases of fulminant hepatitis.

CONCLUSION

The incidence of AHB in HIV positive persons in our cohort was low and shows a progressive decline in the last 20 years. Cases occurred in persons not protected against VHB: not vaccinated or non-responders to vaccine that were not receiving tenofovir.

Baseline prevalence and type distribution of Human papillomavirus in sexually active non-vaccinated adolescent girls from Argentina

In 2011, Argentina launched a government-funded national Human papillomavirus (HPV) immunization program incorporating a bivalent HPV vaccine, with a 0-1-6-month schedule, for girls 11 years of age, born after January 2000. Monitoring the changes of HPV infection prevalence among young women has been proposed as an endpoint for early assessment of HPV vaccination programs. However, the data on HPV prevalence at young ages are very limited. The aim of this work was to determine the prevalence of HPV infection and type-specific distribution in sexually active 15-17-year-old non-vaccinated girls. Cervical samples from 1073 adolescents were collected for HPV detection and genotyping using the BSGP5+/GP6+PCR-reverse line blot (RLB) assay. Out of 957 specimens analyzed, 56.3% were positive for any HPV type; 42.2% harbored at least one high-risk HPV (HR-HPV) type and 30.8% low-risk HPV (LR-HPV) types. Multiple and single infections were identified in 36.3% and 20.0% of the samples respectively. The 6 most common HR-HPV types were HPV16 (11.1%), HPV52 (10.8%), HPV56 (8.3%), HPV51 (7.4%), HPV58 (7.3%) and HPV31 (7.1%). The prevalence of HR-HPV-16/18 was 15.2%. In conclusion, results confirm that HPV (particularly HR-types) are very common among sexually active adolescents, and prevalence rises quickly after their sexual debut. Our HPV type-specific prevalence baseline may be used to monitor post-vaccinal longitudinal changes in Argentina.

Update on malaria

Despite recent successful efforts to reduce the global malaria burden, this disease remains a significant global health problem. Only in 2018, malaria caused 228 million clinical episodes, 2-4 million of which were severe malaria cases, and 405,000 were fatal. Most of the malaria attributable mortality occurred among children in sub-Saharan Africa. Nowadays, rapid diagnostic tests and artemisinin derivatives are two of the main pillars for the management of malaria. However, considering the current situation, these strategies are not sufficient to maintain a reducing trend in malaria incidence and mortality. New insights into the pathophysiology of malaria have highlighted the importance of the host response to infection. Understanding this response would help to develop new diagnostic and therapeutic tools. Vector and parasite drug resistance are two major challenges for malaria control that require special attention. The most advanced malaria vaccine (RTS,S) is currently being piloted in 3 African countries.

Epidemiologic study of Haemophilus influenzae causing invasive and non-invasive disease in Paraguay (1999-2017)

INTRODUCTION

Haemophilus influenzae is a cause of mild and severe invasive infections, especially among children under 5 years old. Serotype b (Hib) was very frequent before the introduction of the vaccine, which was introduced in Paraguay in 2004.

METHODS

A total of 523 isolates of H. influenzae obtained from 1999 to 2017 and referred to the National Reference Laboratory in Paraguay were studied by conventional microbiological methods and molecular techniques.

RESULTS

The most frequent serotype was non-typeable (HiNT) (51.8%; 271/523), followed by Hib (43%; 225/523), Hia and Hif (1.5%; 8/523, respectively), Hic (1%; 5/523), Hie (0.8%; 4/523), and Hid (0.4%; 2/523). A total of 48.4% invasive infections were caused by HiNT, and 46.1% by Hib; 88.6% of isolates corresponded to meningitis, 70.8% to sepsis and 50.9% to pneumonia in children under 5 years. A total of 84% (181/217) of isolates corresponded to invasive infections caused by Hib in children under 5 years, with the highest proportion observed between 2001 and 2003. The most prevalent biotypes were biotype I (29%), biotype II (12%), biotype III (24%), and biotype IV (13%). Among the total of isolates, 13% (68/523) of isolates were resistant to ampicillin.

CONCLUSION

After the introduction of the Hib vaccine in Paraguay, the number of invasive Hib cases decreased in children under 5 years old, although we observed an increase of HiNT in children over 5 years. Continuous surveillance is necessary in order to monitor the effectiveness of the vaccine and for the development of preventive interventions.

Distribution of PCV13 and PPSV23 Streptococcus pneumoniae serotypes in Argentinean adults with invasive disease, 2013-2017

Streptococcus pneumoniae is a major cause of severe invasive disease associated with high mortality and morbidity worldwide. To identify the serotypes most commonly associated with infection in adults in Argentina, 791 pneumococcal isolates from 56 hospitals belonging to 16 provinces and Buenos Aires city were serotyped. The isolates were submitted as part of a National Surveillance Program for invasive pneumococcal disease in adults, which started in 2013. Serotypes 3, 8, 12F, 7F and 1 were the most prevalent among adult patients. During the study period there was no significant difference in serotype distribution between the age groups studied (18-64 and ≥65 years old), except for serotype 1, 3 and 23A. Most prevalent serotypes in pneumonia were serotype 7F, 1, 12F, 8, and 3. When the clinical diagnosis was meningitis, serotype 3 and 12F were the most prevalent, whereas when the diagnosis was sepsis/bacteremia the most prevalent was serotype 8. In this work, for the 18-64-year-old group, PPSV23 and PCV13 serotypes accounted for 74.56% and 44.54% respectively of the cases in the studied period. On the other hand, for the ≥65-year-old group, these serotypes represented 72.30% and 41.42% respectively. The aim of this work was to establish the knowledge bases of the serotypes that cause invasive pneumococcal diseases in the adult population in Argentina and to be able to detect changes in their distribution over time in order to explore the potential serotype coverage of the vaccines in current use.

Spanish newsreel NO-DO (1943-1975). The diffusion of science as a legitimizing instrument of the Franco regime: polio and other immuno-preventable diseases

The official NO-DO newsreels were screened in Spain on a weekly basis from 1943 to 1981. These official news and documentary programmes were compulsory in cinemas from the moment they were first produced until the end of the Francoist dictatorship (1975). NO-DO held an information monopoly and was used as the regime's propaganda tool to indoctrinate the population, building stories tailored to the regime's interests and masking social realities. In this study, we examined newsreels on medical subjects relating to diseases preventable by vaccination. A majority of reports centred on poliomyelitis, and two differentiated periods could be defined, coinciding with the development of Franco regime's foreign policy. Further, from the gender perspective, we analyse the female stereotypes in the battle against vaccine preventable diseases Therefore, the news coverage of polio is of special relevance. In conclusion, this topic offers a good opportunity to reflect on the political role of popular science and science communication in a specific historical context.

[Immunisation schedule of the Spanish Association of Paediatrics: 2019 recommendations]

The Advisory Committee on Vaccines of the Spanish Association of Paediatrics annually publishes the immunisation schedule considered optimal for children resident in Spain, according to available evidence on current vaccines. As regards funded immunisations, the 2+1 strategy (2, 4, 11 months) with hexavalent (DTPa-IPV-Hib-HB) and 13-valent pneumococcal vaccines are recommended. Administration of the 6-year booster dose with DTPa is recommended, with a poliomyelitis dose for children who had received the 2+1 scheme, as well as Tdap vaccine for adolescents and pregnant women in every pregnancy between 27 and 32 weeks gestation. The 2-dose scheme should be used for MMR (12 months and 3-4 years) and varicella (15 months and 3-4 years). MMRV vaccine could be applied as the second dose. Vaccination against HPV is recommended in both genders, preferably at 12 years of age. A stronger effort should be made to improve vaccination coverage. The new 9-valent vaccine is now available, expanding the coverage for both genders. Tetravalent meningococcal vaccine (MenACWY) is recommended at 12 months and 12-14 years, with a catch-up up at 19 years of age. It is also recommended in infants older than 6 weeks of age with risk factors, or travellers to countries with high incidence of ACWY meningococcal serogroups. As regards non-funded immunisations, it is recommended meningococcal B vaccination, with a 2+1 schedule, and requests that it be included in the National Immunisation Program. Vaccination against rotavirus is recommended in all infants.

[Prevention and treatment of infectious diseases in diabetic patients]

The bidirectional relationship between infectious diseases and diabetes is well-known. On the one hand, diabetes patients are at a higher risk of presenting with infectious diseases, possibly with more severity, and on the other hand, infectious diseases impair metabolic control in patients with diabetes. Population ageing arises partly due to an increased survival rate in chronic diseases, of which diabetes is amongst them. Improving infectious disease prevention could reduce complications arising from the former diseases, consequences of decompensated diabetes condition (morbidity, incapacity, hospital admissions, healthcare costs, and mortality rates) and result in improved quality of life in patients with diabetes. The current review presents the treatment of infectious diseases in patients with diabetes and the dealing with immuno-preventable diseases with the currently advised vaccinations.

[Evaluation of pain in children of 2, 4 and 6 months after the application of non-pharmacological analgesia methods during vaccination]

INTRODUCTION

Young children perceive pain as much, or even more than adults, and the pain may have short- and long-term consequences. The literature describes the use of non-pharmacological interventions to alleviate pain during vaccination. The aim of this study was to assess 3such interventions for analgesia during vaccination: non-nutritive sucking (NNS), breastfeeding (BF), and administration of a 50% dextrose solution (D50W).

MATERIALS AND METHODS

A prospective, non-randomised cohort study was carried out on infants aged 2, 4 and 6 months that received 1, 2, or 3 vaccines, respectively, according to the routine immunisation schedule. There were 3treatments: NNS, BF, and 2mL of D50W combined with NNS. Pain was assessed using the LLANTO scale, and the duration of crying.

RESULTS

The study included 387 infants. The mean scores in the LLANTO scale at ages 2 and 6 months were significantly lower in breastfed infants compared to infants managed with NNS (P=.025 and P<.001, respectively), or infants given D50W (P=.025 and P=.001), and the difference was not statistically significant at age 4 months (P=.21 and P=.27). There were no significant differences between infants managed with NNS and D50W at 2, 4, and 6 months (P=.66, P=.93 and P=.45, respectively). The duration of crying was significantly lower at age 6 months in breastfeed infants compared to infants managed with NNS or D50W (P=.013 and P=.017). No breastfed child (n=129) experienced side effects.

CONCLUSIONS

In infants born to term with adequate weight for gestational age, breastfeeding reduces pain on the administration of 1 or 2 vaccines. When 3 vaccines are given, the reduction is minimal. Administration of D50W does not have any additional analgesic effect in infants compared to being held by a parent combined with NNS during vaccination. BF during vaccination is not associated with any side effects.

[False beliefs about vaccines]

Las vacunas constituyen un instrumento esencial para la prevención de enfermedades infecciosas. Sin embargo, las falsas ideas y rumores sin fundamento científico sobre eventuales efectos negativos pueden disuadir de la vacunación, con los consiguientes riesgos para la protección de la población. El objetivo del artículo es evaluar el origen y los argumentos de algunos de los errores y rumores más frecuentes sobre eventuales efectos adversos de las vacunaciones. Se presentan algunos efectos adversos claramente establecidos, así como falsas creencias sobre diversas vacunas y potenciales daños para la salud. Las vacunas, como cualquier fármaco, pueden ocasionar efectos adversos, pero los eventuales efectos adversos de los programas de vacunación son claramente inferiores a sus beneficios individuales (a los vacunados) y colectivos (a los vacunados y a los que no pueden vacunarse por razones médicas). Cualquier efecto indeseable atribuible a las vacunas ha de poderse detectar mediante sistemas de farmacovigilancia potentes y bien estructurados.

[The battle in Madrid over poliomyelitis vaccines (1963): science, ideology and power in the first mass immunization campaign in Spain]

Between 1958 and 1963, Spain witnessed the highest ever incidence of poliomyelitis (2000 cases and 200 deaths per year). Although Salk's inactivated vaccine had arrived in Spain in 1957, the government took no decisive action to administer it to the entire population at risk. Neither was Sabin's attenuated vaccine administered, available in Europe from 1960. While other countries adopted one or the other, in Spain rivalry arose over the two vaccines, with mixed results. The Salk vaccine was administered to a small percentage of the population at risk through the Compulsory Sickness Insurance scheme (Spanish initials: SOE), while at the same time a research team at the National School of Health led by Florencio Pérez Gallardo (1917-2006) carried out a model epidemiological study that demonstrated the superiority of the Sabin vaccine. In 1963, the SOE launched a national campaign with the Salk vaccine promoted by the paediatrician Juan Bosch Marín (1902-1995), a representative of the most conservative structure of the Franco regime. The dispute over which vaccine was best reached its peak in early 1963 at various scientific conferences in Madrid. Bosch Marín's group argued in favour of his campaign and the Salk vaccine, while Pérez Gallardo did the same for the oral vaccine, achieving a substantial impact by inviting Sabin himself to speak. By the end of the year, following a pilot study, the first mass oral vaccination campaign against polio was introduced in Spain.

[Immunisation schedule of the Spanish Association of Paediatrics: 2018 recommendations]

The Advisory Committee on Vaccines of the Spanish Association of Paediatrics annually publishes the immunisation schedule considered optimal for children resident in Spain, according to available evidence on current vaccines. Regarding funded immunisations, 2+1 strategy (2, 4, 11-12 months) with hexavalent (DTPa-IPV-Hib-HB) and 13-valent pneumococcal vaccines are recommended. Administration of the 6-year booster dose with DTPa is recommended, and a poliomyelitis dose for children who had received the 2+1 scheme, as well as Tdap vaccine for adolescents and pregnant women in every pregnancy between 27 and 32 weeks' gestation. The two-dose scheme should be used for MMR (12 months and 2-4 years) and varicella (15 months and 2-4 years). MMRV vaccine could be applied as the second dose if available. Coverage of human papillomavirus vaccination in girls aged 12 with a two dose scheme (0, 6 months) should be improved. Information and recommendation for male adolescents about potential beneficial effects of this immunisation should be provided as well. The new 9 genotypes vaccine is now available, expanding the coverage for both gender. Regarding non-funded immunisations, Committee on Vaccines of the Spanish Association of Paediatrics recommends meningococcal B vaccination, with a 3+1 schedule, and requests to be included in the National Immunisation Program. Tetravalent meningococcal vaccine (MenACWY) is recommended to adolescents (14-18 years) who are going to live in countries with systematic vaccination against ACWY serogroups, and people >6 weeks of age with risk factors or travellers to countries with very high incidence. Vaccination against rotavirus is recommended in all infants.

[Decrease in the incidence of chickenpox in the Community of Madrid after universal childhood immunization. Years 2001-2015]

OBJECTIVE

Varicella vaccine was recommended in the Community of Madrid (CM) at 15months of age between November 2006 and December 2013. The objective was to describe the impact of vaccination on the incidence of varicella in the CM during the period 2001-2015.

DESIGN

A descriptive study of cases of varicella reported to the Sentinel Physician Network of the CM and the cases recorded in the Minimum Basic Data Set at hospital discharge was carried out. Total incidence of cases and of hospital admissions were calculated, as well as specific incidence by age and sex.

RESULTS

The incidence was 94.0% lower between 2012 and 2013 than between 2001 and 2003. Between 2014 and 2015 the incidence was 61.8% higher than between 2012 and 2013. The highest incidence was observed in children aged 0 to 4years except for 2010-2014, which was exceeded by the incidence in children aged 5 to 9. The trend in hospital admissions was also decreasing, with the highest incidence in children aged 0 to 1year, followed by 1-4years.

CONCLUSIONS

There has been a significant decrease in the incidence of cases and of hospital admissions by varicella in all age groups after the recommendation to vaccinate at 15months of age, which is compatible with the effectiveness of a dose and its ability to produce immunity group. The withdrawal of this recommendation between 2014 and 2015 has led to an increase in the incidence.

[Vaccine hesitancy: discourse analysis of parents who have not fully or partially vaccinated their children]

OBJECTIVE

To analyse and understand vaccination hesitancy discourses, particularly those of people who have decided not to vaccinate their sons and daughters.

METHODS

Qualitative study of five individual interviews and two focus groups with people who chose not to vaccinate their children in the province of Granada (Spain).

RESULTS

Mothers and fathers manifest a system of health beliefs different to the biomedical paradigm. From an ethical point of view, they justify their position based on the right to autonomy and responsibility for their decisions. Alleged specific reasons: they doubt administration of several vaccines simultaneously at an early age in a systematic way and without individualising each case; they fear adverse effects and do not understand the variations of the vaccination schedule.

CONCLUSIONS

These vaccination hesitancy discourses respond to the individual vs collective conflict; parents defend their right to bring up their children without any interference from the state and focus their responsibility on the individual welfare of their sons and daughters, regardless of the consequences that their actions might have on the collective. In their management of risks, they consider those derived from vaccination more relevant than the individual or collective consequences of not doing so. The vaccines generating most doubts are the more controversial ones within the scientific world. Transparency in communication of adverse effects; authorities respect for other health/disease concepts; banishment of the term "anti-vaccines" from the media and scientific vocabulary, and developing spaces for dialogue are bridges to be built.

[Orbital cellulitis complicated by subperiosteal abscess due to Streptococcus pyogenes infection]

BACKGROUND

Orbital cellulitis is an infectious disease that is very common in pediatric patients, in which severe complications may develop. Etiological agents related to this disease are Haemophilus influenzae B, Staphylococcus aureus, Streptococcus pneumoniae and Moraxella catarrhalis, which correspond to 95% of cases. Moreover, Streptococcus beta hemolytic and anaerobic microorganisms may also be present corresponding to < 5% of the cases. We present an uncommon case of cellulitis complicated by sub-periosteal abscess caused by Streptococcus pyogenes (Group A beta hemolytic streptococcus).

CASE REPORT

A 9-year-old male patient with a history of deficit disorder and hyperactivity since 5 years of age. His current condition started with erythema in the external edge of the right eye, increase in peri-orbicular volume with limitation of eyelid opening, progression to proptosis, pain with eye movements and conjunctival purulent discharge. Image studies reported subperiosteal abscess and preseptal right with extraocular cellulitis. The patient started with empirical antibiotic treatment, surgical drainage and culture of purulent material from which Streptococcus pyogenes was isolated.

CONCLUSIONS

Due to the implementation of vaccination schemes against H. influenza and S. pneumoniae since the 90s, the cases by these pathogens have decreased, causing new bacteria to take place as the cause of the infection. The importance of considering S. pyogenes as an etiology of orbital cellulitis is the rapid progression to abscess formation, and the few cases described in the literature.

[Immunisation schedule of the Spanish Association of Paediatrics: 2015 recommendations]

The Advisory Committee on Vaccines of the Spanish Association of Paediatrics updates the immunisation schedule every year, taking into account epidemiological data as well as evidence on the safety, effectiveness and efficiency of current vaccines, including levels of recommendation. In our opinion, this is the optimal vaccination calendar for all children resident in Spain. Regarding the vaccines included in the official unified immunization schedule, the Committee emphasizes the administration of the first dose of hepatitis B either at birth or at 2 months of life; the recommendation of the first dose of MMR and varicella vaccine at the age of 12 months, with the second dose at the age of 2-3 years; DTaP or Tdap vaccine at the age of 6 years, followed by another Tdap booster dose at 11-12 years old; Tdap strategies for pregnant women and household contacts of the newborn, and immunization against human papillomavirus in girls aged 11-12 years old with a 2 dose scheme (0, 6 months). The Committee reasserts its recommendation to include vaccination against pneumococcal disease in the routine immunisation schedule, the same as it is being conducted in Western European countries. The recently authorised meningococcal B vaccine, currently blocked in Spain, exhibits the profile of a universal vaccine. The Committe insists on the need of having the vaccine available in communitary pharmacies. It has also proposed the free availability of varicella vaccines. Their efectiveness and safety have been confirmed when they are administred from the second year of life. Vaccination against rotavirus is recommended in all infants. The Committee stresses the need to vaccinate population groups considered at risk against influenza and hepatitis A.

[Vaccine cold chain interruption in a primary care center and economic evaluation]

OBJECTIVES

Cold chain control is one of the most important facts to ensure the effectiveness of vaccines links, which requires specific material and human resources for management. The principal objective is to evaluate the interruptions in cold chain of the last 6 years and the possible cost savings that would result in further improvements.

METHOD

A retrospective and descriptive study based on a review of all cold chain interruptions during the last 6 years, at Valdefierro Primary Health Center.

RESULTS

We had 5 interruptions, the maximum temperature reached was 23.1±3.4°C and the longest interruption lasted 25.2±20.7hours. 1611 vaccines were affected and 165 discarded. Total economic loss was 2.098,10 € and 33.611,64 € were savings. The electrical failure was the disruption cause in 5 cases.

CONCLUSIONS

Equipment and staff are essential. The center did some corrective actions, such as minimizing refrigerator time control, minimum stock control, considering population changes, and the center has requested a electrical supply system.

[Vaccination counselling: The meeting point is possible]

INTRODUCTION

There are recommendations for decision-making as regards parents who do not vaccinate their children, but there are few publications analysing this problem. In November 2014, a pioneer medical clinic opened in Spain, for counselling on immunisation practices. The aim of this study is to determine the success of the recommendations of the American and Spanish Paediatrics Associations according to the number of parents who finally accept vaccination.

PATIENTS AND METHODS

A descriptive, cross-sectional, prospective and single-centre study was conducted from November 2014 to March 2016. Children under the age of 16 not properly vaccinated, according to the immunisation schedule of the region where the study was conducted, were included after signing informed consent.

RESULTS

A total of 20 families were counselled. The median age of the children was 2 years, and 80% of them received no vaccine. Absolute non-acceptance of vaccination was practiced by 45% of parents. The main reasons for not vaccinating were: 100% thimerosal-containing, 90% risk of autism, 85% aluminium-containing, 70% presence of other stabilisers and preservatives, and 65% risk of anaphylaxis. The immunisation advice was said to be helpful by 90% of parents. Vaccination was accepted by 90% of parents (45% completely).

CONCLUSIONS

Anti-vaccination ideologies are strong and hard to change. Paediatricians not denying medical care to parents who endanger the lives of their own children are also hard to find. The meeting point is possible, and society needs it. Active listening, empathy, and good quality information were the keys to our results.

[Vaccination for international travelers]

Traveler's vaccination is one of the key strategies for the prevention of infectious diseases during international travel. The risk of acquiring an infectious disease is determined in each case by the characteristics of the traveler and the travel, so the pre-departure medical advice of the traveler must be individualized. The World Health Organization classifies travelerś vaccines into three groups. - Vaccines for routine use in national immunization programs: Haemophilus influenzae type b, hepatitis B, polio, measles-mumps-rubella, tetanus-diphtheria-whooping a cough, and chickenpox. - Vaccinations required by law in certain countries before to enter them: yellow fever, meningococcal disease and poliomyelitis. - Vaccines recommended depending on the circumstances: cholera, japanese encephalitis, tick-borne encephalitis, meningococcal disease, typhoid fever, influenza, hepatitis A, hepatitis B, rabies and BCG. This review is intended to introduce the reader to the field of international vaccination.

[Immunisation schedule of the Spanish Association of Paediatrics: 2016 recommendations]

The Advisory Committee on Vaccines of the Spanish Association of Paediatrics (CAV-AEP) annually publishes the immunisation schedule which, in our opinion, estimates optimal for children resident in Spain, considering available evidence on current vaccines. We acknowledge the effort of the Ministry of Health during the last year in order to optimize the funded unified Spanish vaccination schedule, with the recent inclusion of pneumococcal and varicella vaccination in early infancy. Regarding the funded vaccines included in the official unified immunization schedule, taking into account available data, CAV-AEP recommends 2+1 strategy (2, 4 and 12 months) with hexavalent (DTPa-IPV-Hib-HB) vaccines and 13-valent pneumococcal conjugate vaccine. Administration of Tdap and poliomyelitis booster dose at the age of 6 is recommended, as well as Tdap vaccine for adolescents and pregnant women, between 27-36 weeks gestation. The two-dose scheme should be used for MMR (12 months and 2-4 years) and varicella (15 months and 2-4 years). Coverage of human papillomavirus vaccination in girls aged 11-12 with a two dose scheme (0, 6 months) should be improved. Information for male adolescents about potential beneficial effects of this immunisation should be provided as well. Regarding recommended unfunded immunisations, CAV-AEP recommends the administration of meningococcal B vaccine, due to the current availability in Spanish communitary pharmacies, with a 3+1 scheme (3, 5, 7 and 13-15 months). CAV-AEP requests the incorporation of this vaccine in the funded unified schedule. Vaccination against rotavirus is recommended in all infants. Annual influenza immunisation and vaccination against hepatitis A are indicated in population groups considered at risk.

[Parental decisions that do not risk children's lives but place them at significant harm: foregoing vaccination]

The decisions of parents to forego vaccines "mandatory" for their children generate in physician and pediatricians some dilemmas and issues such as what to do when parents do not authorize administration of vaccines to their children? Do parents place their children at risk severe enough to notify governmental child protection services and treat this as parental negligence? What to do in the situation where the parental decision to forego immunization of their children affects others? The best interests of the child include ensuring the child's benefit over any other situation. Related to this, parents against vaccines have arguments to justify their position that physicians cannot force parents to immunize their children. By the same principle, physicians must ensure the welfare of children and remain alert, respecting that parental decisions do not exceed the threshold of "no harm to the child" and only if the parental decision in regard to foregoing vaccination places the child at risk of serious harm is government intervention justified. This resource should be left as the last resort because most conflicts must be resolved within the relationship of the physicians with the parents.

[Acceptability of human papillomavirus vaccine in mothers from Valencia (Spain)]

INTRODUCTION

In October 2008, Valencian Community started its human papillomavirus (HPV) vaccination schedules for 14 year-old girls. The aim of this study is to assess knowledge about HPV infection and its vaccine among the mothers of these girls, and to identify factors associated with the willingness to vaccinate their daughters.

MATERIAL AND METHODS

Cross-sectional study by means of a questionnaire to mothers of girls born in 1995, and attending secondary schools in the province of Valencia during 2010-2011. Cluster stratified random sample (n=1279).

STATISTICAL ANALYSIS

percentages, confidence intervals, OR, Chi-squared and multivariate logistic regression contrasts.

RESULTS

A total of 833 (65.1%) questionnaires were completed. The results obtained showed that, 76.6% of mothers had vaccinated their daughters against HPV; 93.8% knew about the vaccine, particularly through television (71.5%); and 78.5% received positive advice from a health professional which increased the vaccination of their daughters (OR: 2.4). There was low overall knowledge about HPV infection and vaccination. Confidence of the mothers in vaccines as a preventative method increases the HPV vaccination (OR: 3.8). The first reason for refusal was the fear of adverse events (45.6%).

CONCLUSIONS

Apparently, the media does not influence the willingness to vaccinate. It would be desirable to minimize the perception of risk of the vaccine. Positive health advice from a health professional can have a positive effect on vaccination. There is a gap between the level of knowledge and decision-making to vaccinate.

[Community acquired pneumonia in children: Outpatient treatment and prevention]

There have been significant changes in community acquired pneumonia (CAP) in children in the last decade. These changes relate to epidemiology and clinical presentation. Resistance to antibiotics is also a changing issue. These all have to be considered when treating CAP. In this document, two of the main Spanish pediatric societies involved in the treatment of CAP in children, propose a consensus concerning therapeutic approach. These societies are the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases. The Advisory Committee on Vaccines of the Spanish Association of Paediatrics (CAV-AEP) has also been involved in the prevention of CAP. An attempt is made to provide up-to-date guidelines to all paediatricians. The first part of the statement presents the approach to ambulatory, previously healthy children. We also review the prevention with currently available vaccines. In a next second part, special situations and complicated forms will be addressed.

[Vaccination against meningococcal B disease. Public statement of the Advisory Committee on Vaccines of the Spanish Association of Paediatrics (CAV-AEP)]

Meningococcal invasive disease, including the main clinical presentation forms (sepsis and meningitis), is a severe and potentially lethal infection caused by different serogroups of Neisseria meningitidis. Meningococcal serogroup B is the most prevalent in Europe. Most cases occur in children, with a mortality rate of 10% and a risk of permanent sequelae of 20-30% among survivors. The highest incidence and case fatality rates are observed in healthy children under 2-3 years old, followed by adolescents, although it can occur at any age. With the arrival in Spain of the only available vaccine against meningococcus B, the Advisory Committee on Vaccines of the Spanish Association of Paediatrics has analysed its preventive potential in detail, as well as its peculiar administrative situation in Spain. The purpose of this document is to publish the statement of the Committee as regards this vaccination and the access to it by the Spanish population, taking into account that it has been only authorized for people at risk. The vaccine is available free in the rest of Europe for those who want to acquire it, and in some countries and regions it has been introduced into the systematic immunisation schedules. The Committee considers that Bexsero® has a profile of a vaccine to be included in the official schedules of all the Spanish autonomous communities and insists on the need for it to be available in pharmacies for its administration in all children older than 2 months.

[Molecular aspects of the antiviral response against hepatitis C virus implicated in vaccines development]

Hepatitis C is a contagious liver disease caused by hepacivirus of the Flaviviridae family. It has a RNA genome, a unique highly variable molecule. It encodes ten proteins which are necessary to infect cells and multiply. Replication occurs only in hepatocytes. Because of its wide genomic variability and the absence of symptoms, it is difficult to make an early diagnosis and successful treatment. In this review we analyze the molecular mechanism by which the virus infects the hepatocytes and causes the disease. We focused the analysis on different therapies, with the possibility of improving treatment with the use of new specific vaccines. We highlight the use of new therapies based on nucleic acids, mainly DNA vectors. In the near future, once this treatment is adequately evaluated in clinical trials, and the costs are calculated, it could be a very beneficial alternative to conventional methods.

Expression of the hemagglutinin HA1 subunit of the equine influenza virus using a baculovirus expression system

Equine influenza virus is a leading cause of respiratory disease in horses worldwide. Disease prevention is by vaccination with inactivated whole virus vaccines. Most current influenza vaccines are generated in embryonated hens' eggs. Virions are harvested from allantoic fluid and chemically inactivated. Although this system has served well over the years, the use of eggs as the substrate for vaccine production has several well-recognized disadvantages (cost, egg supply, waste disposal and yield in eggs). The aim of this study was to evaluate a baculovirus system as a potential method for producing recombinant equine influenza hemagglutinin to be used as a vaccine. The hemagglutinin ectodomain (HA1 subunit) was cloned and expressed using a baculovirus expression vector. The expression was determined by SDS-PAGE and immunoblotting. A high yield, 20μg/ml of viral protein, was obtained from recombinant baculovirus-infected cells. The immune response in BALB/c mice was examined following rHA1 inoculation. Preliminary results show that recombinant hemagglutinin expressed from baculovirus elicits a strong antibody response in mice; therefore it could be used as an antigen for subunit vaccines and diagnostic tests.

[Demands and expectations of parents who refuse vaccinations and perspective of health professional on the refusal to vaccinate]

OBJECTIVES

To examine the opinions, beliefs and attitudes about vaccination, of parents who decide not to vaccinate their children. To determine the opinions and attitudes of the health professionals on the behaviour towards childhood vaccination.

METHOD

Qualitative research based on semi-structured interviews and focal groups in Granada, Spain, including parents who chose to not vaccinate their children, and healthcare professionals who can provide a technical point of view. An analysis was made of the semantic content, and answers were categorized in thematic units.

RESULTS

The parents argued on the benefit of suffering vaccine-preventable diseases in a natural way, without non-natural, aggressive or toxic products. Vaccination was considered unnecessary, if given adequate hygienic-sanitary conditions, effectiveness unproven and more dangerous than the diseases they prevent, especially the polyvalent vaccines. They believed that vaccination programs are moved by biased studies and interests other than prevention. Health care professionals believe that they had fears without scientific basis, which requires improving information systems.

CONCLUSIONS

Non-vaccinators are unaware of the benefit/risk ratio between the vaccination and the individual risk for preventable diseases, and ask for informed consent. Health care professionals believe that non-vaccinators' arguments are not correctly contrasted and expose the existence of failures in actual vaccination coverage and information registration systems. It was suggested to centralize registers and compare them in schools, working with local leaders and reporting regularly on the status of vaccine-preventable diseases.

New treatments for human papillomavirus infection

Human papillomavirus infection is very common. In this article, we review the latest developments in the treatment of lesions caused by this virus, with a particular focus on anogenital warts. Sinecatechins and new imiquimod formulations are among the most significant new developments. Others include photodynamic therapy and intralesional immunotherapy, but there is insufficient evidence to recommend their routine use. Finally, while therapeutic vaccines and inhibitory molecules appear to hold great promise, they are still in the early phases of investigation. More studies are needed, and these should have similar designs, larger samples, and sufficiently long follow-up periods to enable the direct comparison of the short-term and long-term effectiveness of different treatment options.