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MuV caused three epidemic waves in Spain since genotype G emerged in 2005, despite high vaccination coverage. SH gene sequencing according to WHO protocols allowed the identification of seven relevant variants and 88 haplotypes. While the originally imported MuVi/Sheffield.GBR/1.05/-variant prevailed during the first two waves, it was subsequently replaced by other variants originated by either local evolution or importation, according to the additional analysis of hypervariable NCRs. The time of emergence of the MRCA of each MuV variant clade was concordant with the data of the earliest sequence. The analysis of Shannon entropy showed an accumulation of variability on six particular positions as the cause of the increase on the number of circulating SH variants. Consequently, SH gene sequencing needs to be complemented with other more variable markers for mumps surveillance immediately after the emergence of a new genotype, but the subsequent emergence of new SH variants turns it unnecessary.

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In Spain, whole cell pertussis vaccination started in 1975, with three doses before the age of 6-7 months. Doses at 15-18 months and 4-6 years were introduced in 1996 and 2001, respectively. Spain switched to an acellular vaccine in 2005. From 1998 to 2009, pertussis incidence rates remained ≤1.5 cases/100,000 inhabitants but increased from 2010 to 7.5 cases/100,000 in 2012. Data from 1998 to 2012 were analysed to assess disease trends and susceptible populations. We defined four epidemic periods: 1998-2001 (reference), 2002-05, 2006-09 and 2010-12. In 2002-05, the incidence rate increased in individuals aged 15-49 years (IRR: 1.41 (95% CI: 1.11-1.78)) and ≥50 years (IRR: 2.78 (95% CI: 1.78-4.33)) and in 2006-09 increased also in infants aged <3 months (IRR: 1.83 (95% CI: 1.60-2.09)). In 2010-12, the incidence rate increased notably in all age groups, with IRRs ranging between 2.5 (95% CI: 2.3-2.8) in 5-9 year-olds and 36.0 (95% CI: 19.4-66.8) in 20-29 year-olds. These results, consistent with the country's vaccination history, suggest a progressive accumulation of susceptible individuals due to waning immunity after years of low incidence. Further vaccination strategies should be assessed and implemented to prevent pertussis in pre-vaccinated infants, in whom the disease is more severe.

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OBJECTIVE: Comparison of statistical methods and measurement scales to identify nosocomial infection risk factors in intensive care units (ICU). DESIGN: Prospective study in 558 patients admitted to the ICU of a referral hospital between February and November 1994. METHODS: Analysis using three logistic regression models, three standard Cox regression models, and two Cox regression models with time-dependent extrinsic factors. Different scales were used to measure exposures to risk factors (dichotomous, ordinal, quantitative, and time-dependent variables). RESULTS: The most appropriate models were those that measured exposure using dichotomous variables. Models using ordinal or quantitative variables estimated biased coefficients and/or failed to comply with the statistical assumptions underlying the analyses. The Cox regression model with quantitative time-dependent variables met all the statistical assumptions, obtained a precise assessment of risk by exposure time, and estimated unbiased coefficients. CONCLUSIONS: The Cox regression analysis with quantitative time-dependent variables is the most valid alternative for assessing the risk of nosocomial infection per day of exposure to an extrinsic risk factor in the ICU.

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OBJECTIVE: To evaluate the association between nosocomial infections (NI) and the mortality of Intensive Care Unit (ICU) patients, adjusting for the effect on mortality of other predictive variables. METHODS: Prospective study on 944 concurrent patients admitted for at least 24 hours in the ICU of a tertiary level hospital between February and November of 1994. The association between NI (diagnosed using CDC criteria) and mortality was studied using multivariable logistic regression. RESULTS: The cummulative incidence of mortality in the ICU was 11.2% (CI95% = 9.9-12.5). This incidence was significantly higher in infected patients with a crude mortality relative risk of 2.2 (CI95% = 1.5-3.1). In the multivariable analysis, the effect of NI (global, pneumonias, of the urinary tract and bacteriemias) on adjusted mortality depended on the patient's Acute Pysiology and Chronic Health Evaluation II (APACHE II) score. With low APACHE II scores, NI was associated with an increased mortality risk. Conversely, with higher APACHE II scores, the relevance of NI as a determinant of mortality decreased and prognosis was mainly associated with the patient's severity of illness. CONCLUSIONS: The association between NI and mortality, adjusting for other prognostic factors for mortality, is confirmed.

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BACKGROUND: Accidents resulting from percutaneous exposure account for approximately one third of all accidents suffered at work by health workers in hospitals. Their importance lies in the illnesses caused by pathogens that can be transmitted in this way (hepatitis B, hepatitis C, HIV virus). The aims are to describe accidents of this type notified in a tertiary level hospital, identify factors associated with these accidents in nursing staff and build a predictive model for the individual risk of having an accident. METHODS: A descriptive study of a retrospective cohort made up of all the people who notified having suffered an accident between 1-1-93 and 30-6-96. A study of cases and controls in nursing staff during the period 1-1-95 to 30-6-96, analysed through multiple logistical regression. RESULTS: The cumulative incidence of cases of accidents in one year was 0.078 for male and female nurses. In 57.3% of cases, disposable or pre-loaded syringes were involved. The cumulative incidence of cases in one year was greater for intravenous catheterisation (8.5% per 100,000). The risk of having an accident, adjusted on account of confusing variables, was greater for female and male nurses (OR = 3.22; I.C.95% = 1.96-5.27), or workers in the Haemodialysis Unit (OR = 35.21; I.C.95% = 3.74-331.16) and for those employed on a temporary contract (OR = 4.50; I.C.95% = 2.24-9.04). CONCLUSIONS: Accidents resulting from percutaneous exposure at this hospital are more frequent among nursing staff and are basically caused by any type of hollow needles. Factors associated with these accidents were identified, allowing specific prevention programmes to be targeted at those workers at greater risk. The model obtained is valid to estimate the degree of individual accident probability for the subjects studied.

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BACKGROUND: To identify nosocomial infection risk factors in an intensive care unit and construct a predictive model that will enable future risk-adjusted comparisons of infection incidences. PATIENTS AND METHODS: Prospective surveillance of pneumonia, bacteremia and urinary tract infections in intensive care unit patients. All patients (n = 944) admitted to the intensive care unit for at least 24 h were followed daily in a tertiary level hospital. Variables measuring extrinsic as well as intrinsic risk factors for nosocomial infections were collected from each patient during their intensive care unit stay and the Cox proportional hazards multivariable technique was applied to identify the variables mostly associated with infection in our hospital. RESULTS: The main risk factors identified for pneumonias were intrinsic. The hazard ratios (HR) of two extrinsic risk factors were noteworthy: mechanical ventilation (HR = 7.51; 95% CI = 2.95-19.13) and sedation (HR = 2.01; 95% CI = 1.14-3.56). The extrinsic factors associated with bacteremias were, the sum of extrinsic risk factors (HR = 1.52; 95% CI = 1.17-1.97) and having a tracheostomy (HR = 3.61; 95% CI = 1.99-6.56). The urinary tract infections were negatively associated with the administration of antibiotics prior to infection onset (HR = 0.41; 95% CI = 0.21-0.78) and the male sex (HR = 0.40; 95% CI = 0.22-0.75). Conversely, urinary tract infections were positively associated with the presence of cancer (HR = 2.70; 95% CI = 1.03-7.11) and the APACHE II index (for every 5 units of increase of the APACHE II index, HR = 1.39; 95% CI = 1.09-1.79). CONCLUSIONS: The most important risk factors identified for pneumonias and urinary tract infections in intensive care unit patients were endogenous, whereas they were exogenous for bacteremias.

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OBJECTIVE: To identify risk factors predictive of nosocomial infection in an intensive-care unit (ICU) and to identify patients with a higher risk of nosocomial infection using a predictive model of nosocomial infection in our ICU. DESIGN: Prospective study; daily concurrent surveillance of intensive-care-unit patients. SETTING/PATIENTS: All patients admitted for at least 24 hours to the ICU of a tertiary-level hospital from February to November 1994 were followed daily. METHODS: Variables measuring extrinsic and intrinsic risk factors for nosocomial infection were collected on each patient during their ICU stay, and the Cox Proportional Hazards multivariable technique was used to identify the variables significantly associated with infection. RESULTS: The population studied consisted of 944 patients. The main risk factors identified were intrinsic; the significant extrinsic risk factors identified were head of the bed in a horizontal (< 30 degrees) position (this variable presented the highest increase of the infection hazard ratio) and the use of sedative medication. Patients presenting the highest risk scores using the predictive model are those with the highest risk of nosocomial infection. CONCLUSIONS: The important preventive measures derived from our results are that underlying conditions suffered by the patient at the ICU admission should be corrected promptly, the depression of the patient's level of consciousness with sedatives should be monitored carefully, and the horizontal position of the head of the bed should be avoided totally. Patients with a high risk of infection can be the target of special preventive measures.

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BACKGROUND: The constant increase of pharmaceutical costs is of great concern to the administrators of the Spanish National Health Service. Antibiotics administered as prophilaxis prior to surgery, play an important role in this increase. The compliance of physicians with protocols for chemoprophylaxis is therefore an important factor in the control of these pharmaceutical costs. The degree of compliance with the pre-established protocols of prophylaxis prior to surgery are examined in a tertiary level hospital during 1992 and the extra costs due to the lack of compliance with these protocols are estimated using a sample of 371 subjects. The object of this study is to describe the degree of the fulfillment of the protocols of surgical chemoprophylaxis in a tertiary level hospital and to estimate the minimum additional cost due to the wrong chemoprophylaxis. METHODS: A descriptive study was made of the surgical prophylaxis using a sample of 371 subjects. The cost was estimated from the price of the antibiotics administered. RESULTS: A total of 267 (71.9% IC95% = 67.3-76.5) subjects had received incorrect prophylaxis. The most important causes of incorrect prophylaxis were the wrong antibiotic choice and the excessive duration of their administration. The incorrect prophylaxis was responsible for an additional cost of 1,117,287 ptas. The application of these estimates to the entire 1992 surgical population, at our center, would yield an estimated additional cost of 39,409,965 pesetas. CONCLUSIONS: Our health services would have substantial savings if protocols for prophylaxis prior to surgery were strictly followed by physicians.

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The interregional variation coefficient (VC) has been considered as an accurate measure of the dispersion of regional infant, neonatal, postneonatal and perinatal mortality rates. Thus, trends of annual VC have been analyzed, for each rate, from 1940 to 1986, to identify the evolution in time of the regional differences with respect to these mortality rates. None of the four mortality rates showed a decreasing trend in their respective VCs. This may indicate that interregional differences do not change along time. The postneonatal mortality rate has been shown to have the highest VCs during the study period (ranging from 23 to 40%), with an independent evolution with respect to neonatal mortality rate, probably because the factors that influence both rates are clearly different.

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