HPV vaccination programs in LMIC: is it time to optimize schedules and recommendations?

Abstract Objectives: Prophylactic HPV vaccines are a fundamental tool to reduce infections and tumors caused by the most prevalent types of these viruses, as this review points out. Several countries have adopted immunization programs that recommend vaccination against HPV for girls and adolescents between 9 and 14 years of age and, in some of them, also for boys. The programs also contemplate the immunization of adults, particularly in the case of individuals with different immunodeficiencies. Sources of data: The available vaccines are recommended for the prevention of tumors of the uterine cervix, vulva, vagina, penis, and anal canal. Moreover, two of the vaccines prevent the occurrence of genital warts, having been recently indicated for the prevention of oropharyngeal cancer. Data synthesis: Based on the evidence that antibody responses in girls were non-inferior after two doses when compared to three doses, several countries have decided to reduce the vaccination schedule for girls and boys up to 14 years of age from three to two doses, with an interval of six months between them. Recently, knowledge has been accumulating about the immunogenicity, duration of protection, and efficacy of a single-dose HPV vaccine regimen in girls and young women. Conclusion: Single-dose HPV vaccination could substantially reduce the incidence of pre-cancer and cervical cancer attributable to HPV, with reduced costs for vaccine delivery and simplified implementation, allowing more countries to introduce HPV vaccination or increase the adherence of the target population.

Chronic medical conditions associated with invasive pneumococcal diseases in inpatients in teaching hospitals in São Paulo city: Estimating antimicrobial susceptibility and serotype-coverage of pneumococcal vaccines

ABSTRACT Background: Chronic conditions increase the risk of invasive pneumococcal diseases (IPD). Pneumococcal vaccination remarkably reduced IPD morbimortality in vulnerable populations. In Brazil, pneumococcal vaccines are included in the National Immunization Program (PNI): PCV10 for < 2 years-old, and PPV23 for high risk-patients aged ≥ 2 years and institutionalized ≥ 60 years. PCV13 is available in private clinics and recommended in the PNI for individuals with certain underlying conditions. Methods: A retrospective study was performed using clinical data from all inpatients from five hospitals with IPD from 2016 to 2018 and the corresponding data on serotype and antimicrobial-non-susceptibility of pneumococcus. Vaccine-serotype-coverage was estimated. Patients were classified according to presence of comorbidities: healthy, without comorbidities; at-risk, included immunocompetent persons with specific medical conditions; high-risk, with immunocompromising conditions and others Results: 406 IPD cases were evaluated. Among 324 cases with information on medical conditions, children < 5 years were mostly healthy (55.9%), while presence of comorbidity prevailed in adults ≥ 18 years old (> 82.0%). Presence of ≥1 risk condition was reported in ≥ 34.8% of adults. High-risk conditions were more frequent than at-risk in all age groups. Among high-risk comorbidity (n = 211), cancer (28%), HIV/AIDS (25.7%) and hematological diseases (24.5%) were the most frequent. Among at-risk conditions (n = 89), asthma (16.5%) and diabetes (8.1%) were the most frequent. Among 404 isolates, 42.9% belonged to five serotypes: 19A (14.1%), 3 (8.7%), 6C (7.7%), 4 and 8 (6.2% each); 19A and 6C expressed antimicrobial-non-susceptibility. The vaccine-serotype-coverage was: PCV10, 19.1%, PCV13, 43.8%; PCV15, 47.8%; PCV20, 62.9%; PCV21, 65.8%, and PPV23, 67.3%. Information on hospital outcome was available for 283 patients, of which 28.6% died. Mortality was 54.2% for those with meningitis. Conclusion: Vaccine with expanded valence of serotypes is necessary to offer broad prevention to IPD. The present data contribute to pneumococcal vaccination public health policies for vulnerable patients, mainly those with comorbidity and the elderly.

Chronic medical conditions associated with invasive pneumococcal diseases in inpatients in teaching hospitals in São Paulo city: Estimating antimicrobial susceptibility and serotype-coverage of pneumococcal vaccines

Background: Chronic conditions increase the risk of invasive pneumococcal diseases (IPD). Pneumococcal vaccination remarkably reduced IPD morbimortality in vulnerable populations. In Brazil, pneumococcal vaccines are included in the National Immunization Program (PNI): PCV10 for < 2 years-old, and PPV23 for high risk-patients aged ≥ 2 years and institutionalized ≥ 60 years. PCV13 is available in private clinics and recommended in the PNI for individuals with certain underlying conditions. Methods: A retrospective study was performed using clinical data from all inpatients from five hospitals with IPD from 2016 to 2018 and the corresponding data on serotype and antimicrobial-non-susceptibility of pneumococcus. Vaccine-serotype-coverage was estimated. Patients were classified according to presence of comorbidities: healthy, without comorbidities; at-risk, included immunocompetent persons with specific medical conditions; high-risk, with immunocompromising conditions and others RESULTS: 406 IPD cases were evaluated. Among 324 cases with information on medical conditions, children < 5 years were mostly healthy (55.9%), while presence of comorbidity prevailed in adults ≥ 18 years old (> 82.0%). Presence of ≥1 risk condition was reported in ≥ 34.8% of adults. High-risk conditions were more frequent than at-risk in all age groups. Among high-risk comorbidity (n = 211), cancer (28%), HIV/AIDS (25.7%) and hematological diseases (24.5%) were the most frequent. Among at-risk conditions (n = 89), asthma (16.5%) and diabetes (8.1%) were the most frequent. Among 404 isolates, 42.9% belonged to five serotypes: 19A (14.1%), 3 (8.7%), 6C (7.7%), 4 and 8 (6.2% each); 19A and 6C expressed antimicrobial-non-susceptibility. The vaccine-serotype-coverage was: PCV10, 19.1%, PCV13, 43.8%; PCV15, 47.8%; PCV20, 62.9%; PCV21, 65.8%, and PPV23, 67.3%. Information on hospital outcome was available for 283 patients, of which 28.6% died. Mortality was 54.2% for those with meningitis. Conclusion: Vaccine with expanded valence of serotypes is necessary to offer broad prevention to IPD. The present data contribute to pneumococcal vaccination public health policies for vulnerable patients, mainly those with comorbidity and the elderly. Keywords: Antimicrobial resistance; Chronic diseases; Comorbidity; Invasive pneumococcal diseases; Pneumococcal conjugate vaccine; Pneumococcal serotypes; Pneumococcal vaccine.

Brazilian recommendations on the safety and effectiveness of the yellow fever vaccination in patients with chronic immune-mediated inflammatory diseases

Abstract Background: In Brazil, we are facing an alarming epidemic scenario of Yellow fever (YF), which is reaching the most populous areas of the country in unvaccinated people. Vaccination is the only effective tool to prevent YF. In special situations, such as patients with chronic immune-mediated inflammatory diseases (CIMID), undergoing immunosuppressive therapy, as a higher risk of severe adverse events may occur, assessment of the risk-benefit ratio of the yellow fever vaccine (YFV) should be performed on an individual level. Main body of the abstract: Faced with the scarcity of specific orientation on YFV for this special group of patients, the Brazilian Rheumatology Society (BRS) endorsed a project aiming the development of individualized YFV recommendations for patients with CIMID, guided by questions addressed by both medical professionals and patients, followed an internationally validated methodology (GIN-McMaster Guideline Development). Firstly, a systematic review was carried out and an expert panel formed to take part of the decision process, comprising BRS clinical practitioners, as well as individuals from the Brazilian Dermatology Society (BDS), Brazilian Inflammatory Bowel Diseases Study Group (GEDIIB), and specialists on infectious diseases and vaccination (from Tropical Medicine, Infectious Diseases and Immunizations National Societies); in addition, two representatives of patient groups were included as members of the panel. When the quality of the evidence was low or there was a lack of evidence to determine the recommendations, the decisions were based on the expert opinion panel and a Delphi approach was performed. A recommendation was accepted upon achieving ≥80% agreement among the panel, including the patient representatives. As a result, eight recommendations were developed regarding the safety of YFV in patients with CIMID, considering the immunosuppression degree conferred by the treatment used. It was not possible to establish recommendations on the effectiveness of YFV in these patients as there is no consistent evidence to support these recommendations. Conclusion: This paper approaches a real need, assessed by clinicians and patient care groups, to address specific questions on the management of YFV in patients with CIMID living or traveling to YF endemic areas, involving specialists from many areas together with patients, and might have global applicability, contributing to and supporting vaccination practices. We recommended a shared decision-making approach on taking or not the YFV.

Brazilian guidelines for the management of candidiasis - a joint meeting report of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical

Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.

Vacinação contra o vírus influenza em gestantes: cobertura da vacinação e fatores associados / Influenza vaccine in pregnant women: immunization coverage and associated factors

OBJETIVO: Descrever a cobertura vacinal de gestantes para influenza e fatores associados à recusa ou à aceitação da vacina. MÉTODOS: Estudo descritivo, prospectivo, que incluiu 300 puérperas atendidas no Hospital e Maternidade Santa Joana (SP). Os dados foram coletados em outubro de 2010, por meio de questionário pré-testado, aplicado por profissional treinado. RESULTADOS: A média de idade das mães foi 30,5 anos; 231 (77%) eram casadas; 164 (54,7%) primigestas; 192 (64%) tinham nível superior de escolaridade; e 240 (80%) estavam empregadas. Durante o pré-natal, 234 (78%) receberam informação sobre a vacina contra influenza e 287 (95,7%) foram imunizadas; 210 (73,2%) mulheres tinham conhecimento sobre a proteção neonatal pela vacinação materna. Fatores associados à aceitação foram: campanha do governo (133; 44,3%) e recomendação médica durante o pré-natal (163; 54,3%). Entre as 13 grávidas que recusaram a vacinação, as razões foram: negligência (4), falta de tempo (4), falta de indicação médica (3) ou contraindicação pelo médico (2), mas 69,2% teriam sido vacinadas se tivessem sido informadas sobre a proteção neonatal. CONCLUSÃO: O receio da pandemia e a campanha pública tiveram importante impacto na elevada cobertura vacinal para influenza em gestantes. Recomendação médica e campanha do governo foram os principais motivos de aceitação da vacina.

OBJECTIVES: To describe the immunization coverage of the influenza vaccine for pregnant women, and factors associated to vaccination compliance. METHODS: This is a prospective, descriptive study including 300 women who had just given birth at Hospital and Maternity Santa Joana in Sao Paulo, Brazil. Data were collected through a pre-tested questionnaire applied by a trained evaluator during October 2010. RESULTS: The mean age of mothers was 30.5 years; 231 (77%) were married; 164 (54.7%) were primigravidas; 192 (64%) had higher education; and 240 (80%) were employed. During the prenatal period, 234 (78%) received information about the influenza vaccine and 287 (95.7%) were immunized; 210 (73.2%) women knew about neonatal protection achieved through maternal vaccination. The factors associated with maternal acceptance of the vaccine were government campaign (133; 44.3%), and medical recommendation during prenatal visits (163; 54.3%). A total of 13 pregnant women refused vaccination for the following reasons: neglect (4), lack of time (4), lack of recommendation from their physician (3) or contraindication by physician (2), but 69.2% of them would have accepted immunization had they been informed about neonatal protection. CONCLUSIONS: The fear of a pandemic and the public vaccination campaign had an important impact on the high immunization coverage for influenza on pregnant women. Medical recommendation and the government campaign were the main reasons for vaccine compliance.

Vacinas em desenvolvimento: estreptococo do grupo B, herpes-zóster, HIV, malária e dengue / Vaccines under development: group B streptococcus, herpes-zoster, HIV, malaria and dengue

OBJETIVOS: As vacinas contra o estreptococo B, o herpes-zóster, o HIV, a malária e a dengue, selecionadas por critérios de comercialização iminente ou devido a problemas específicos para sua obtenção, foram objeto de uma revisão sobre o estado atual do seu desenvolvimento. FONTE DOS DADOS:Foi realizada revisão da literatura através da MEDLINE no período de 1996 a 2006, sobre a epidemiologia e imunologia das doenças, analisando tanto os maiores problemas para a obtenção de uma vacina como o estado atual dos estudos, com ênfase para os que estavam em fase mais adiantada. SíNTESE DOS DADOS: Cada uma das cinco doenças escolhidas apresenta problemas específicos para o desenvolvimento de uma vacina. No entanto, a maioria deles já foi ou está em vias de ser resolvido, permitindo prever que uma vacina - ou vacinas - eficaz e segura estará disponível em futuro próximo. CONCLUSÕES:Apesar dos problemas enfrentados para o desenvolvimento dessas vacinas, os avanços da biologia molecular e da imunologia permitiram superar a maioria deles, abrindo a perspectiva para a obtenção de novas vacinas.

A survey of the incidence of neonatal sepsis by group B Streptococcus during a decade in a Brazilian maternity hospital

Group B Streptococcus (GBS) is the main etiological agent of neonatal sepsis in developed countries, however there is no detailed information on its incidence in Brazil. We registered the incidence and lethality of GBS infection in a Brazilian private maternity hospital from April 1991 to March 2000. Maternal risk factors contributing to neonatal infections were also scored. The rate of infection was determined by checking for GBS in the blood and liquor of symptomatic neonates within 72 hours of birth. Sepsis and/or early onset meningitis were diagnosed in 43 neonates (32 cases in blood, 1in liquor and 10 in blood and liquor). The overall incidence was 0.39 per thousand neonates and remained quite constant throughout the period, ranging from 0.25-0.63. Septic shock occurred in 33 neonates within 1 to 36 hours of birth (mean 15 hours). Among those patients, 26 (60) died between the 5th and the 85th hour after birth. Maternal risk factors, according to CDC criteria, included: gestational age below 37 weeks in 26 cases (60), amniorrhexis equal or superior to 18 hours in 7 cases (16), and maternal temperature equal or superior to 38(o)C in 4 cases (9). None of the mothers had received prophylactic antibiotics during labor nor were urine, rectal or vaginal swabs screened for GBS. Although the incidence of GBS infection in the population in this study was lower than that found in developed countries, its rate of mortality was higher. The death rate could be reduced through recognition of the risk factors and prophylactic antibiotics during labor.

Listeriose neonatal / Neonatal listeriosis

Os autores descrevem e discutem três casos de infecçäo por Listeria mono cytogenes no período de janeiro de 1994 a dezembro de 1995, diagnosticados na Unidade Neonatal do Hospital e Maternidade Santa Joana, Säo Paulo. Nos três casos observamos líquido amniótico meconial. Em dois havia história materna de infecçäo de vias urinárias, fisometria e a idade gestacional (IG) era menor que 35 semanas. O quadro clínico nestes casos foi mais grave, evoluindo para óbito em menos de 24 horas. O terceiro recém-nascido(RN) tinha uma IG de 37 semanas, sem antecedentes de patologias maternas e a evoluçäo clínica foi satisfatória. É importante lembrar que o obstetra de estar atento para situaçöes de risco, já que o tratamento precoce da mäe pode modificar a...

Controle e prevençäo de infecçäo hospitalar: fontes de agentes infecciosos e meios de transmissäo, isolamento / Control and prevention of nosocomial infection: infectious agents' source and transmission paths, isolation

O objetivo deste artigo é fazermos uma breve revisäo das fontes e meios de transmissäo dos agentes de infecçäo em Neonatologia. Para o bom conhecimento das medidas de prevençäo e controle de infecçöes hospitalares é fundamental que saibamos os mecanismos de transmissäo dos agentes infecciosos. A cadeia epidemiológica das infecçöes nosocomiais nos recém-nascidos é formada por seis componentes: o próprio recém-nascido, seus mecanismos de transmissäo (direto, indireto e por veículo) e as estratégias no controle das infecçöes. As infecçöes nosocomiais em neonatologia englobam aquelas cuja transmissäo ocorre via canal de parto (estreptococo do grupo B) e aquelas adquiridas no berçário propriamente ditas.

Antibioticoprofilaxia em cirurgia. Noçöes gerais / Antibiotic prophylaxis in surgery. General ideas

Os autores discutem definiçäo, uso lógico e utilizaçäo racional de profilaxia antibiótica, enfatizando a necessidade de respaldo de tal uso na literatura médica; apresentam normatizaçäo de drogas e tempos de uso que correspondem a uma análise crítica dos trabalhos publicados, que mostram a utilidade da antibioticoprofilaxia segundo os vários procedimentos