Diálogos continentais sobre comunicação em saúde em tempos de pandemia / Continental dialogues on health communication in times of pandemic

Esta publicação, a 6ª da série LEIASS (Linha Editorial Internacional de Apoio aos Sistemas de Saúde), é fruto dos esforços conjuntos do Conselho Nacional de Secretários de Saúde do Brasil (CONASS) e do Instituto de Higiene e Medicina Tropical da Universidade Nova de Lisboa em reunir artigos de destacados autores, de diferentes países, sobre o importante tema da Comunicação em Saúde, nestes tempos de pandemia da Covid-19. Além de autores do Brasil e Portugal, estão também presentes neste volume artigos de especialistas do Canadá, Estados Unidos da América, Inglaterra, México e Uruguai, a quem agradecemos o valioso contributo à discussão. Um agradecimento especial deve ser feito à Profa. Dra. Ana Valéria Machado Mendonça, da Universidade de Brasília, que aceitou nosso convite para encarregar-se de organizar a presente obra. Há uma riqueza imensa de assuntos, que incluem a promoção da saúde; a revisão sistemática sobre o processo de comunicação em saúde na vigência da pandemia; a comunicação direcionada a povos indígenas; as questões afetas à saúde mental; a desinformação e o papel da mídia, dentre outros. Esperamos que a partilha de pontos de vista distintos, que envolvem realidades próprias a cada um desses países, possa auxiliar na compreensão do que se tem assistido em nível global em matéria de comunicação em saúde e suas repercussões no sucesso ou nas dificuldades enfrentadas face à pandemia da COVID-19.

SARS-CoV-2 and influenza: a comparative overview and treatment implications / SARS-CoV-2 e influenza: revisión comparativa e implicaciones del tratamiento

Abstract Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and Alphainfluenzavirus are RNA viruses that cause coronavirus disease-19 and influenza, respectively. Both viruses infect the respiratory tract, show similar symptoms, and use surface proteins to infect the host. Influenza requires hemagglutinin and neuraminidase to infect, whereas SARS-CoV-2 uses protein S. Both viruses depend on a viral RNA polymerase to express their proteins, but only SARS-CoV-2 has a proofreading mechanism, which results in a low mutation rate compared to influenza. E1KC4 and camostat mesylate are potential inhibitors of SARS-CoV-2 S protein, achieving an effect similar to oseltamivir. Due to the SARS-CoV-2 low mutation rate, nucleoside analogs have been developed (such as EIDD-2801), which insert lethal mutations in the viral RNA. Furthermore, the SARS-CoV-2 low mutation rate suggests that a vaccine, as well as the immunity developed in recovered patients, could provide long-lasting protection compared to vaccines against influenza, which are rendered obsolete as the virus mutates.

Resumen La enfermedad por coronavirus de 2019 y la influenza son causadas por virus ARN: coronavirus tipo 2 del síndrome respiratorio agudo grave (SARS-CoV-2) y Alphainfluenzavirus, respectivamente. Ambos virus infectan el tracto respiratorio, presentan síntomas similares y emplean proteínas de superficie para infectar al huésped. El virus de la influenza requiere de hemaglutinina y neuraminidasa para infectar, mientras que el SARS-CoV-2 utiliza la proteína S. Ambos virus dependen de la ARN polimerasa viral para expresar sus proteínas, pero solo el SARS-CoV-2 cuenta con un mecanismo de corrección de errores, por lo que presenta una baja tasa de mutaciones en comparación con el virus de la influenza. E1KC4 y el mesilato de camostat son inhibidores potenciales de la proteína S del SARS-CoV-2, obteniendo un efecto similar al de oseltamivir. Aprovechando la baja tasa de mutación del SARS-CoV-2, se han desarrollado análogos de nucleósidos (como el fármaco EIDD-2801) que insertan mutaciones letales en el ARN viral. Además, la baja tasa de mutación del SARS-CoV-2, obteniendo un efecto similar al de oseltamivir sugiere que las vacunas desarrolladas, así como la inmunidad generada en pacientes recuperados, podrían brindar protección prolongada, en comparación con las vacunas desarrolladas contra la influenza, que resultan obsoletas frente a una cepa mutada.

O que o passado tem a nos ensinar sobre a Influenza? / What does the past have to teach us about influenza? / ¿Qué puede enseñarnos el pasado sobre la Influenza?

Objetivo: apresentar narrativa dos acontecimentos históricos sobre a epidemia de Influenza e suas interfaces com a saúde pública e enfermagem. Conteúdo: destaca-se a cultura, e os modos de ver a história ao longo dos anos para compreensão do comportamento epidemiológico da Influenza no Brasil, suas epidemias e o que se apreendeu e construiu após 100 anos cuidando e estudando sobre este agravo durante as epidemias que ocorreram no Brasil. Conclusão: entender que a imunização é a estratégia mais eficaz no controle de doenças transmissíveis e, no caso da Influenza, como imunobiológico potente, deve ser o legado apreendido das grandes epidemias deste agravo, mas também, a vigilância e educação em saúde das populações para tal, principalmente com foco nos movimentos antivacinas.

Objective: to present a narrative of historical events regarding the influenza epidemic and its interfaces with public health and nursing. Content: the study highlights culture and ways of seeing history over the years, in order to understand the epidemiological behavior of influenza in Brazil, its epidemics, and what has been learned and built after 100 years' caring for and studying this condition during epidemics that occurred in Brazil. Conclusion: immunization is the most effective strategy for controlling communicable diseases and, in the case of Influenza, is a powerful immunobiological resource. This should be the legacy learned from the major epidemics of this disease, as well as health surveillance and education of the public for the same purpose, with a special focus on anti-vaccine movements.

Objetivo: presentar narrativa de los sucesos históricos sobre la epidemia de Influenza y sus interfaces con la salud pública y la enfermería. Contenido: se destacan la cultura y los modos de ver la historia a lo largo de los años, para comprender el comportamiento epidemiológico de la Influenza en Brasil, sus epidemias y lo que se aprendió y construyó después de 100 años cuidando y estudiando sobre este agravio durante las epidemias que ocurrieron en Brasil. Conclusión: entender que la inmunización es la estrategia más eficaz en el control de enfermedades transmisibles y, en el caso de la Influenza, como inmunobiológico potente, ese debe ser el legado comprendido de las grandes epidemias. Asimismo, se debe llevar en cuenta la vigilancia y la educación en salud de las poblaciones, principalmente con foco en los movimientos antivacunas.

Immunogenicity and safety of Southern Hemisphere inactivated quadrivalent influenza vaccine: a Phase III, open-label study of adults in Brazil

Abstract The World Health Organization influenza forecast now includes an influenza B strain from each of the influenza B lineages (B/Yamagata and B/Victoria) for inclusion in seasonal influenza vaccines. Traditional trivalent influenza vaccines include an influenza B strain from one lineage, but because two influenza B lineages frequently co-circulate, the effectiveness of trivalent vaccines may be reduced in seasons of influenza B vaccine-mismatch. Thus, quadrivalent vaccines may potentially reduce the burden of influenza compared with trivalent vaccines.In this Phase III, open-label study, we assessed the immunogenicity and safety of Southern Hemisphere inactivated quadrivalent influenza vaccine (Fluarix™ Tetra) in Brazilian adults (NCT02369341). The primary objective was to assess hemagglutination-inhibition antibody responses against each vaccine strain 21 days after vaccination in adults (aged ≥18–60 years) and older adults (aged >60 years). Solicited adverse events for four days post-vaccination, and unsolicited adverse events and serious adverse events for 21 days post-vaccination were also assessed.A total of 63 adults and 57 older adults received one dose of inactivated quadrivalent influenza vaccine at the beginning of the 2015 Southern Hemisphere influenza season. After vaccination, in adults and older adults, the hemagglutination-inhibition titers fulfilled the European licensure criteria for immunogenicity. In adults, the seroprotection rates with HI titer ≥1:40 were 100% (A/H1N1), 98.4% (A/H3N2), 100% (B/Yamagata), and 100% (B/Victoria); in older adults were 94.7% (A/H1N1), 96.5% (A/H3N2), 100% (B/Yamagata), and 100% (B/Victoria). Pain was the most common solicited local adverse events in adults (27/62) and in older adults (13/57), and the most common solicited general adverse events in adults was myalgia (9/62), and in older adults were myalgia and arthralgia (both 2/57). Unsolicited adverse events were reported by 11/63 adults and 10/57 older adults.The study showed that inactivated quadrivalent influenza vaccine was immunogenic and well-tolerated in Brazilian adults and older adults.

Improving influenza vaccination rates of healthcare workers: a multipronged approach in Qatar

We assessed whether an influenza vaccination [IV] campaign was effective at increasing vaccination rate in healthcare workers [HCWs] in 2 hospitals in Doha, Qatar that had no mandatory IV policy. The campaign comprised promotional, educational and vaccine delivery interventions; a dedicated IV team; telephone hotline; free IV with improved access, leadership involvement; incentives; group educational sessions; and reporting/tracking activities. During the 2014/15 influenza season, IV rates according to hospital and HCW category were calculated and compared with the 2 seasons before the intervention. The combined mean rate for IV for both hospitals increased for 2014/15 [64.3%] compared with 2013/14 [37.2%] and 2012/13 [28.4%]. There was increased IV uptake among doctors and nurses at each hospital, and the IV rate for the 2 hospitals [59.1 and 69.5%] were higher than in 2013/14 [21.1% and 53.2%] and 2012/13 [17.2% and 39.6%]. The findings highlight the importance of improving IV rates among HCWs in hospitals with no mandatory vaccination policies through multicomponent interventions

Contribution of laboratories in the WHO Eastern Mediterranean Region to the selection of candidate seasonal influenza vaccine, 2010-2015

The World Health Organization [WHO] formulates recommendations for viruses to be included in vaccines for the influenza seasons in the northern and southern hemispheres on the basis of analyses by its collaborating centres [CCs]. This report describes the contribution of influenza laboratories and national influenza centres in countries in the WHO Region for the Eastern Mediterranean to the selection process of seasonal and pre-pandemic influenza virus subtypes. Data submitted by 22 countries to FluNet and FluID between September 2010 and June 2015 were analysed. National Influenza Centres [NICs] in 12 countries [55%] reported data, 5 [23%] to both FluNet and FluID and 7 [32%] only to FluNet. The WHO CC in London characterized 78% of the samples, and the CC in Atlanta, characterized 21%. The contribution of influenza laboratories and NICs from this Region to global influenza surveillance is appreciable. However, enhancing the contribution through initiatives such as the Pandemic Influenza Preparedness Framework is still needed

Fatores associados à adesão à vacinação anti-influenza em idosos não institucionalizados, São Paulo, Brasil / Factores relacionados con la adhesión a la vacunación antigripal en ancianos que viven en la comunidad, São Paulo, Brasil / Factors associated with adherence to influenza vaccination among non-institutionalized elderly in São Paulo, Brazil

Resumo O objetivo do estudo foi estimar a cobertura vacinal contra a influenza em idosos e identificar os fatores associados à adesão à vacinação. Foi realizado estudo transversal de base populacional, com dados coletados, em 2006, pelo estudo Saúde, Bem-estar e Envelhecimento. A amostra foi composta por 1.399 idosos do Município de São Paulo, Brasil. A associação entre a adesão à vacina e as variáveis independentes foi avaliada por meio da razão de prevalências, estimada pela regressão de Poisson. A vacinação autorreferida foi de 73,8%. No modelo explicativo final, a vacinação contra a gripe foi associada à idade mais elevada, à presença de doenças crônicas e ao atendimento à saúde no ano anterior. Foi observada associação negativa com a internação no ano anterior. Concluiu-se ser necessário incentivar a vacinação de idosos com menos de 70 anos e sem doenças crônicas, assim como orientar os profissionais de saúde para ampliar a cobertura nos grupos com menor participação nas campanhas.

Resumen El objetivo del estudio fue estimar la cobertura de vacunación contra la gripe en los ancianos e identificar los factores asociados con la adherencia a la vacunación. Un estudio poblacional de corte transversal, con los datos recogidos en 2006 por el estudio Salud, Bienestar y Envejecimiento. Participaron 1.399 adultos mayores de São Paulo, Brasil. La asociación entre la adherencia a la vacuna y las variables independientes fue evaluada por razones de prevalencia, estimada por la regresión de Poisson. El auto-reporte de vacunación fue 73,8%. La vacunación antigripal fue asociada a edad avanzada, presencia de enfermedades crónicas y atención de salud en el año anterior. Fue observada una asociación negativa con la hospitalización en el año anterior. Se concluyó que era necesario fomentar la vacunación de las personas mayores con menos de 70 años y sin enfermedades crónicas y orientar a los profesionales de la salud para ampliar la cobertura en los grupos con menor participación en las campañas.

Abstract The objectives of this study were to estimate influenza vaccination coverage in the elderly and identify factors associated with vaccination uptake. A cross-sectional population-based study was conducted with data collected in 2006 by the Health, Well-Being, and Aging study. The sample consisted of 1,399 elderly in the city of São Paulo, Brazil. The association between vaccine uptake and independent variables was assessed with prevalence ratios, estimated by Poisson regression. Self-reported vaccination was 73.8%. In the final explanatory model, influenza vaccination was associated with older age, presence of chronic diseases, and use of health care in the previous year. A negative association was observed with hospitalization during the previous year. The study concludes that it is necessary to encourage vaccination of elderly less than 70 years of age and those without chronic diseases, as well as to orient health professionals to expand coverage in groups with lower uptake during vaccination campaigns.

Comparative study of lymphocytes from individuals that were vaccinated and unvaccinated against the pandemic 2009-2011 H1N1 influenza virus in Southern Brazil

ABSTRACTINTRODUCTION:While no single factor is sufficient to guarantee the success of influenza vaccine programs, knowledge of the levels of immunity in local populations is critical. Here, we analyzed influenza immunity in a population from Southern Brazil, a region with weather conditions that are distinct from those in the rest of country, where influenza infections are endemic, and where greater than 50% of the population is vaccinated annually.METHODS:Peripheral blood mononuclear cells were isolated from 40 individuals. Of these, 20 had received the H1N1 vaccine, while the remaining 20 were unvaccinated against the disease. Cells were stimulated in vitro with the trivalent post-pandemic influenza vaccine or with conserved major histocompatibility complex I (MHC I) peptides derived from hemagglutinin and neuraminidase. Cell viability was then analyzed by [3-(4,5-dimethylthiazol-2-yl)-2,5- diphenyltetrazolium bromide)]-based colorimetric assay (MTT), and culture supernatants were assayed for helper T type 1 (Th1) and Th2-specific cytokine levels.RESULTS:Peripheral blood lymphocytes from vaccinated, but not unvaccinated, individuals exhibited significant proliferation in vitro in the presence of a cognate influenza antigen. After culturing with vaccine antigens, cells from vaccinated individuals produced similar levels of interleukin (IL)-10 and interferon (IFN)-γ, while those from unvaccinated individuals produced higher levels of IFN-γ than of IL-10.CONCLUSIONS:Our data indicate that peripheral blood lymphocytes from vaccinated individuals are stimulated upon encountering a cognate antigen, but did not support the hypothesis that cross-reactive responses related to previous infections can ameliorate the immune response. Moreover, monitoring IL-10 production in vaccinated individuals could comprise a valuable tool for predicting disease evolution.

Comparison of the direct fluorescence assay and real-time polymerase chain reaction for the detection of influenza virus A and B in immunocompromised patients

OBJECTIVE: This study evaluated the diagnostic performance of two methods for the detection of influenza virus in immunocompromised transplant patients. METHODS: A total of 475 respiratory samples, 236 from patients in a hematopoietic stem cell transplantation program and 239 from kidney transplant patients, were analyzed by a direct fluorescence assay and the Centers for Disease Control real-time polymerase chain reaction protocol for influenza A and B detection. RESULTS: Influenza detection using either method was 7.6% in the hematopoietic stem cell transplant group and 30.5% in the kidney transplant patient group. Influenza detection by real-time polymerase chain reaction yielded a higher positive rate compared with fluorescence than that reported by other studies, and this difference was more pronounced for influenza A. The fluorescence assay sensitivity, specificity, positive and negative predictive values, and kappa coefficient were 17.6%, 100%, 1, 0.83, and 0.256, respectively, and lower detection rates occurred in the kidney transplant patients. CONCLUSIONS: The real-time polymerase chain reaction performance and the associated turnaround time for a large number of samples support the choice of this method for use in different routine diagnostic settings and influenza surveillance in high-risk patients. .

Eventos adversos pós-vacinação contra influenza pandêmica A (H1N1) 2009 em crianças / Adverse events following vaccination against pandemic influenza A (H1N1) 2009 in children

O objetivo do estudo foi estimar a frequência e os fatores associados à ocorrência de eventos adversos pós-vacinação contra a influenza pandêmica A (H1N1) 2009 em crianças com idade entre seis meses e dois anos. Participaram do estudo 156 crianças. Modelos multivariados de regressão de Cox foram construídos para avaliar a associação independente de cada covariável e a queixa de pelo menos um evento adverso. A força da associação foi medida pela hazard ratio e seus respectivos intervalos de 95% de confiança. Após a primeira dose, foi relatado algum tipo de evento adverso por 40,3% dos participantes e, após a segunda, por 35,5%. Os eventos sistêmicos foram mais frequentes que os locais, destaque para irritabilidade, diarreia e febre. As incidências de eventos adversos, no geral e sistêmicos, após a primeira dose, foram maiores nas crianças com doença concomitante/alergia em relação àquelas sem o agravo (HR = 3,43; IC95%: 1,34-8,77 e HR = 2,76; IC95%: 1,11-6,89). A maioria dos eventos foi de intensidade leve. Febre alta, vômito e diarreia motivaram a busca por serviços de saúde.

The aim of this study was to estimate the frequency of adverse events following vaccination against pandemic influenza A (H1N1) 2009 and associated factors in children from six months to two years of age (n = 156). Multivariate Cox regression was used to assess the independent associations between covariates and complaints of at least one adverse event. Strength of association was measured by hazard ratios and respective 95% confidence intervals. Following the first dose, 40.3% of parents reported one or more adverse events in their children, compared to 35.5% after the second dose. Systemic adverse events, specifically irritation, diarrhea, and fever, were more frequent than local reactions at the vaccination site. Incidence rates for adverse events in general and systemic reactions following the first dose were higher in children with concomitant illness or allergies (HR = 3.43, 95%CI: 1.34-8.77 and HR = 2.76, 95%CI: 1.11-6.89). Most events were mild. Cases of high fever, vomiting, and diarrhea prompted parents to seek care for their children at health services.

Consultation on estimation of burden of influenza in EMRO

The Communicable Disease Surveillance, Forecasting and Response [CSR] unit in the Office for the Eastern Mediterranean Region [EMR] of WHO organized a consulta-tion meeting on the tools for estimating the burden of Influenza and other Acute Respiratory Infections [ARI] in Cairo during the period 15-17 May 2012. In this consultation, experts from GIP in WHO HQ, University of Edinburgh, Royal College London in UK, Field Epidemiology Training Program in Pakistan and WHO Temporary Advisers participated and discussed application of WHO manuals and guidelines in the EMR

Importancia de las imágenes y el diagnóstico etiológico en el paciente inmunocomprometido con afección del sistema nervioso central: Segunda parte / Importance of images and etiological diagnosis in the immunocompromised patient with central nervous system envolvement: Part II

We present the case of a 12-year-old boy with acute lymphocytic leukemia who developed pneumonia and multiple brain infarcts compatible with acute necrotic encephalitis. The infectious disease screening tests revealed influenza A H1N1 virus, Staphylococcus aureus in broncho alveolar lavage, E. coli and galactomannan antigen in blood. CNS influenza associated complications are reviewed. This case highlights the importance of magnetic resonance imaging as a diagnostic tool in the assessment of immunocompromised patients with CNS compromise and the value of brain biopsy in the final identification of an infectious disease etiology.

Escolar de 12 años de edad, con Leucemia Linfocítica Aguda en tratamiento que desarrolla una bronconeumonía bilateral, infartos cerebrales compatibles con encefalitis necrosante aguda. El estudio infectológico demostró más de una causas infecciosa que pudiera explicar su evolución destacando influenza A H1N1, Staphylococcus aureus meticilina sensible en lavado bronco alveolar, E. coli y galactomanano en sangre. Se revisa el compromiso del SNC por influenza A H1N1. Se destaca la importancia del uso de resonancia magnética nuclear al evaluar pacientes inmunocomprometidos con complicaciones neurológicas y el aporte de una biopsia cerebral en aclarar la etiología de este compromiso.

Desempeño de la prueba de inmunofluorescencia directa en el diagnóstico del virus Influenza A(H1N1) / Direct immunofluorescence assay performance in diagnosis of the Influenza A(H1N1) virus

El 25 de abril de 2009, a menos de un mes de la detección en México del primer humano con virus Influenza A(H1N1), la enfermedad ya se había propagado a más de 40 países superando los 10 000 casos notificados. Dada su naturaleza impredecible, este tipo de virus requiere métodos diagnósticos apropiados, confiables y seguros, pero que también estén al alcance de los laboratorios clínicos. Mediante el estudio de 291 muestras de pacientes con sospecha de infección por virus Influenza A(H1N1) en Neuquén, Argentina, el presente trabajo compara los dos métodos de diagnóstico utilizados simultáneamente: la prueba de inmunofluorescencia directa (DFA) y la de reacción en cadena de la polimerasa en tiempo real (RT-PCR). La DFA dio una sensibilidad de 44,4 por ciento, especificidad de 99,6 por ciento, valor predictivo positivo de 95,2 por ciento y valor predictivo negativo de 90,7 por ciento. Los resultados positivos de la metodología pueden considerarse verdaderos positivos. Un resultado negativo no excluye la presencia del virus y la muestra debe examinarse mediante RT-PCR. Del total de 291 muestras, 45 resultaron positivas por RT-PCR y 21 por DFA.

By 25 April 2009, less than one month after the first human with Influenza A(H1N1) virus was detected in Mexico, the disease had already spread to more than 40 countries, with over 10 000 cases reported. Due to its unpredictability, this type of virus requires appropriate, reliable, and safe diagnostic methods that are also accessible to clinical laboratories. Through the analysis of 291 samples taken from patients with suspected Influenza A(H1N1) virus infection in Neuquén, Argentina, this study compares the two diagnostic methods used simultaneously: direct immunofluorescence assay (DFA) and real-time polymerase chain reaction (RT-PCR). DFA had a sensitivity of 44.4 percent, a specificity of 99.6 percent, a positive predictive value of 95.2 percent, and a negative predictive value of 90.7 percent. Positive results obtained with this method can be considered true positives. A negative result does not rule out the presence of the virus. In this case, the sample should be examined by RT-PCR. Out of a total of 291 samples, there were 45 positive results with RT-PCR and 21 positive results with DFA.

Reverse genetic platform for inactivated and live-attenuated influenza vaccine

Influenza vaccine strains have been traditionally developed by annual reassortment between vaccine donor strain and the epidemic virulent strains. The classical method requires screening and genotyping of the vaccine strain among various reassortant viruses, which are usually laborious and time-consuming. Here we developed an efficient reverse genetic system to generate the 6:2 reassortant vaccine virus from cDNAs derived from the influenza RNAs. Thus, cDNAs of the two RNAs coding for surface antigens, haemagglutinin and neuraminidase from the epidemic virus and the 6 internal genes from the donor strain were transfected into cells and the infectious viruses of 6:2 defined RNA ratio were rescued. X-31 virus (a high-growth virus in embryonated eggs) and its cold-adapted strain X-31 ca were judiciously chosen as donor strains for the generation of inactivated vaccine and live-attenuated vaccine, respectively. The growth properties of these recombinant viruses in embryonated chicken eggs and MDCK cell were indistinguishable as compared to those generated by classical reassortment process. Based on the reverse genetic system, we generated 6 + 2 reassortant avian influenza vaccine strains corresponding to the A/Chicken/Korea/MS96 (H9N2) and A/Indonesia/5/2005 (H5N1). The results would serve as technical platform for the generation of both injectable inactivated vaccine and the nasal spray live attenuated vaccine for the prevention of influenza epidemics and pandemics.

Pneumonia por Influenza A(H1N1) em paciente imunossuprimido após transplante cardíaco / Influenza A (H1N1) pneumonia in an immunossupressed patient after heart transplantation / Neumonía por Influenza A (H1N1) en paciente inmunosuprimido tras transplante cardiaco

O papel da resposta imunológica durante a infecção pelo vírus Influenza H1N1 não está totalmente estabelecido, mas acredita-se que atue de forma decisiva no agravamento do quadro e no aparecimento da síndrome de desconforto respiratório agudo. O papel de terapias imunomoduladoras no controle de infecções virais também não é consensual e faltam dados de literatura para se definir as indicações de seu uso. Neste relato de caso, apresentamos, segundo nosso conhecimento, pela primeira vez, o relato de um paciente transplantado cardíaco que apresentou infecção pelo vírus H1N1 e evoluiu de forma favorável, trazendo um questionamento sobre o real papel da terapia imunossupressora como fator de risco para a forma grave da doença.

The role of the immune response during Influenza H1N1 virus infection is not yet fully established, but it is believed that it decisively participates in the severity of the disease as well as in the development of acute respiratory distress syndrome. The role of immunomodulating therapies in the control of viral infections is not a consensus either, and data from the literature defining the indications for their use are lacking. The present report is, to our knowledge, the first on a heart transplant patient who developed H1N1 virus infection and had a favorable outcome, thus generating discussion on the real role of immunosuppressive therapy as a risk factor for the severe form of the disease.

El rol de la respuesta inmunológica durante la infección por el virus Influenza H1N1 no está totalmente establecido, sino que se cree que él actúe de forma decisiva en el agravamiento del cuadro y en el surgimiento del síndrome de distrés respiratorio agudo. El papel de terapias inmunomoduladoras en el control de infecciones virales también no es consensual y nos faltan datos de la literatura para definirse las indicaciones de su utilización. En este caso clínico presentamos, según nuestro conocimiento, por primera vez, el relato de un paciente transplantado cardiaco que presentó infección por el virus H1N1 y evolucionó de forma favorable, y aprovechamos para poner en cuestión el real papel de la terapia inmunosupresora como factor de riesgo para la forma severa de la enfermedad.

Síntomas gripales asociados a la vacunación antigripal en personal de salud / Flu-like symptoms associated with influenza vaccination in health personnel

Introducción: En el Hospital Italiano de Buenos Aires se realizó una campaña de vacunación masiva destinada al personalde la institución durante mayo de 2009.Objetivo: Medir síntomas gripales asociados a la vacunación en personal de salud. Métodos: Estudio de cohorte. Se compararon, mediante riesgo relativo, las incidencias de los síntomas gripales informados para la semana epidemiológica 20, por 400 vacunados durante dicha semana y 400 no vacunados, apareados por edad, sexo y profesión. Los síntomas comunicados dentro de las 48 horas posteriores a la vacunación se consideraron secundarios a ella. Resultados: Fueron encuestados 583 (72.5%) de los cuales 281 vacunados y 302 no vacunados: edad media 36 (DS 11) vs. 35.2 (DS 10.5); mujeres 54% vs. 57% y médicos 21% vs. 18%. En la semana de vacunación presentaron fiebre 12.46% vs. 6.95% (RR 1.79, IC95% 1.07-3), coriza 24.2% vs. 17.22% (RR 1.41 IC95%1.02-1.94), odinofagia 11.74% vs. 0.33%(RR 35.47 IC 95% 4.88-257), dolor corporal 18.86% vs. 14.57% (RR 1.29 IC 95% 0.9-1.87) vacunados y no vacunados, respectivamente. Se atribuyen a la vacuna: dolor corporal 9.25% (IC95% 6.3-13.6), coriza 8.19% (IC95% 5.4-12.31); fiebre 6.78% (IC95% 4.31-10.6) y odinofagia 4.27% (IC 95% 2.42-7.5). Y dolor de brazo 65%. Los médicos no informaronmayor frecuencia de síntomas gripales.Discusión: En la literatura, la odinofagia y la coriza no están asociadas a la vacunación, la frecuencia de los otros síntomas a las 48 horas fue similar a la informada. Conclusión: El síndrome gripal fue descripto con mayor frecuencia entre los vacunados y puede ser resultado de un sesgo de reporte.

Introduction: In May 2009, prior to the beginning of winter in the Southern hemisphere, a massive vaccination campaign for the personnel was performed at the Hospital Italiano de Buenos Aires. Objective: To assess symptoms associated with influenza vaccination in health personnel. Methods: In a cohort study, the impact of flu symptoms reported for the epidemiological week number 20 were compared using the relative risk between 400 vaccinated vs. 400 unvaccinated individuals matched for age, sex and occupation. Symptoms reported within 48 hours after vaccination were considered secondary this event. Results: 583 people were respondents (72.5%) of whom 281 were vaccinated vs. 302 who were unvaccinated (mean age, 36 yr (SD 11 yr) vs. 35.2 yr (SD 10.5 yr); women, 54% vs. 57%; doctors 21% vs. 18%, respectively). During the vaccination week, 12.46% vaccinated vs. 6.95% unvaccinated individuals presented fever (RR 1.79, CI95% 1.07-3); a cold, 24.2% vs. 17.2% (RR 1.41, CI95% 1.02-1.94); sore throat, 11.74% vs. 0.33% (RR 35.47, CI 95% 4.88-257); body pain, 18.86% vs. 14.57% (RR 1.29, CI 95% 0.9-1.87), respectively. Symptoms attributed to the vaccine were: body pain, 9.25% (CI95% 6.3-13.6); cold, 8.19% (CI95% 5.4-12.31); fever, 6.78% (CI95% 4.31-10.6); sore throat, 4.27% (CI 95% 2.42-7.5); and arm pain, 65%. Doctors did not report a higher frequency of flu symptoms.Discussion: Sore throat and cold are not symptoms commonly reported in association with vaccination. The frequency of other symptoms following the first 48 hours of vaccination was similar to previous reports. Conclusion: The flu syndrome was reported more frequently in vaccinated people as compared with those unvaccinated.However, these results might be due to a reporting bias.

Connections: can the 20th century coronary heart disease epidemic reveal something about the 1918 influenza lethality?

This essay proposes that the ecologic association shown between the 20th century coronary heart disease epidemic and the 1918 influenza pandemic could shed light on the mechanism associated with the high lethality of the latter. It suggests that an autoimmune interference at the apoB-LDL interface could explain both hypercholesterolemia and inflammation (through interference with the cellular metabolism of arachidonic acid). Autoimmune inflammation, then, would explain the 1950s-60s acute coronary events (coronary thrombosis upon influenza re-infection) and the respiratory failure seen among young adults in 1918. This hypothesis also argues that the lethality of the 1918 pandemic may have not depended so much on the 1918 virus as on an immune vulnerability to it, possibly resulting from an earlier priming of cohorts born around 1890 by the 1890 influenza pandemic virus.