Seroprevalence of antibodies to the influenza A (H1N1) virus among healthcare workers prior to the 2009 pandemic peak | Enfermedades Infecciosas y Microbiología Clínica

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"Olalla" "email" => array:1 [ 0 => "Julio.olalla@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Fernando" "apellidos" => "de Ory" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Inmaculada" "apellidos" => "Casas" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "Alfonso" "apellidos" => "del Arco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Natalia" "apellidos" => "Montiel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => 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"afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Internal Medicine Department, Hospital Costa del Sol, Marbella, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP)" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Diagnostic Microbiology Service, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Influenza and Respiratory Disease Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Microbiology Laboratory, Hospital Costa del Sol, Marbella, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Research Unit, Hospital Costa del Sol, Marbella, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Seroprevalencia de anticuerpos frente al virus influenza A(H1N1)2009 entre trabajadores sanitarios al principio de la pandemia" ] ] "textoCompleto" => "IntroductionIn April 2009, the first cases among humans of Influenza A (H1N1) 2009 virus were confirmed in Mexico and the USA,<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> and in June 2009, a pandemic situation was declared by the World Health Organisation. From the outset, cases of nosocomial transmission were confirmed, affecting healthcare staff.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Moreover, previous experience with Severe Acute Respiratory Syndrome (SARS) in SE Asia<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> led researchers to believe that healthcare workers would be particularly vulnerable to the appearance of this new virus.However, the first series to be published did not show healthcare workers to be over-represented in the incidence of symptomatic cases.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> It is hypothesised that as a result of their greater exposure to the virus at work, they acquire higher immunity than that present in the general population. To date, few studies have been made of seroprevalence among healthcare workers,<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> and the results reported have been contradictory.In the present study, we propose to determine the seroprevalence of antibodies to the influenza A virus of the 2009 pandemic among a population of healthcare workers. It is hypothesised that exposure to the virus varies according to the areas of work within the hospital and according to the professional category of the worker, following a gradient of greater to lesser exposure depending on the area of hospital in question (Emergencies>Medical Area>Surgical Area).Material and methodsStudy population and time horizonThis transversal study was carried out at Hospital Costa del Sol in Marbella (Spain). The hospital has around 350 beds and serves a reference population of 372,964 persons, according to data from the Spanish National Statistical Institute on January 1, 2009.Participation in the study was proposed at discussions with permanent staff in of Emergency, Internal Medicine and Pneumology departments (medical area) and General Surgery and Anaesthesia (surgical area). Further collaboration was provided by the emergency staff at the High Resolution Specialist Centre (HARE) associated with the hospital. At this latter centre, emergency cases are attended and short-term beds (not exceeding 72h) are available. According to their professional category, the participating personnel were divided into doctors, nurses, nursing auxiliary staff, orderlies and administrative staff.The participants gave their written signed consent and completed a questionnaire on the presence or otherwise of influenza-related symptoms, and comorbidities associated with a poor prognosis of influenza A.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Also included were questions on the subject's state of seasonal and pandemic influenza vaccination, any cases of influenza in the immediate family, daily handwashing at work and at home, pharmacological treatment taken for influenza A, a diagnosis of seasonal influenza or of influenza A infection (the latter confirmed by PCR-positive nasal swab). The main study variable was the presence of titres against the new influenza A virus ≥1/40.Sample collection began on 25 August 2009 and concluded on 16 September 2009. This study was approved by the hospital's ethics committee.Sample processingThe samples were kept in cold storage at our hospital, before being sent to the National Microbiology Centre at Majadahonda (Madrid, Spain), where they were analysed to detect antibodies against the influenza A virus responsible for the 2009 pandemic; this analysis was performed using the haemagglutination inhibition technique, in a modification of a method previously described.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>The antibody titres for each serum was the greatest dilution presenting inhibition of the haemagglutination power of the viral antigen. Sera were considered positive with titres equal to or greater than 1:40.Statistical analysisA descriptive analysis was performed, with measures of central tendency and dispersion for the continuous variables, and of frequency distribution for the qualitative ones. In the bivariate analysis, the principle variable was the presence or absence of IHA+ (≥1/40), with the subgroups in the continuous variables being compared by means of the Mann-Whitney U test, while the categoric variables were compared using the chi square test, or Fisher's exact test, when necessary, for the qualitative ones. For the IHA+ result variable, we constructed forward selection multiple logistic regression models, including the variables which in the bivariate analysis obtained p<0.01, with an entry criterion of 0.05 and an output criterion of 0.1, including the odds ratio (OR) values and 95% confidence intervals (95%CI). The level of statistical significance was established at p<0.05.ResultsA total of 239 healthcare workers participated in the study: 113 (47.3%) worked in the emergency department, 49 (20.5%) in the medical area, 46 (19.2%) in the surgical area and 31 (13%) in the emergency department of the peripheral centre associated with the hospital. The principal characteristics of the participants are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, including the symptoms reported at the moment the blood sample was taken. None of the participants reported suffering dyspnea.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>None of the workers were diagnosed with influenza A, nor had any been vaccinated against this virus. However, 11 (4.6%) workers were diagnosed with seasonal influenza and 40 (16.7%) were vaccinated against seasonal influenza. Only one worker was taking medication (oseltamivir) for this. 60 (25.1%) participants presented antibody titres determined by IHA ≥1/40. The geometric mean of these values was 58.56.The proportion of positive results was significantly different among the diverse hospital departments: 36.6% in the emergency department, 12.2% in the medical area, 22.2% in the surgical area and 9.7% in the peripheral centre associated with the hospital (p=0.001). We also observed differences by professional category, with positive results among 30.8% of the doctors, 11.1% of the nurses, 30.2% of the nursing auxiliary staff, 23.1% of the administrative staff and 41.7% of the orderlies (p=0.01).A positive serology was recorded among 31.4% of the women vs. 14% of the men (49 females vs. 12 males, p=0.009). There were no differences in average age between seropositive and seronegative subjects. None of the comorbidities were associated with a greater prevalence of positive serologies. With respect to symptoms, only the presence of rhinorrhoea on the day the serology was determined and was significantly associated with a greater proportion of seropositive subjects (57.1% vs. 23.3%, p=0.009). There were no differences with respect to influenza diagnosed among other family members or whether or not vaccination against seasonal influenza had been received. Of the 11 workers who had been diagnosed with seasonal influenza, 6 (54.5%) presented a positive serology, vs. 23.9% of the other subjects (p=0.03). The geometric mean of the antibody levels in these 6 patients was higher than that of those who had not been diagnosed with seasonal influenza, although without reaching statistical significance (80 vs. 56.56, p=0.32).An initial logistic regression analysis was performed, in which the outcome variable was the presentation of positive serology (IHA≥1/40), and in which the independent variables were gender, age, the hospital area in which the worker was active, professional category, the presence of rhinorrhoea, and the prior diagnosis of seasonal influenza. The factors subsequently maintained in the model were female gender (OR 2.28, 95%CI: 1.05–4.95), rhinorrhoea (OR 3.71, 95%CI: 1.09–12.63) and prior diagnosis of influenza (OR 5.24, 95%CI: 1.32–20.82), as well as the professional categories of orderly, administrative staff and doctor. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarises the results of the logistic regression analysis.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>A second model was constructed, excluding the workers who had previously been diagnosed with seasonal influenza. The results of this are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. In this model, the factors subsequently maintained were rhinorrhoea (OR of 3.65; 95%CI: 1.03–12.92), working in the emergencies area (OR of 3.84, 95%CI: 1.04–14.09) and professional category of doctor, administrative staff or orderly (OR of 8.19, 7.22 and 7.21, respectively).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionIn our series, we observed a high prevalence of healthcare workers presenting positive serology for the influenza A virus responsible for the 2009 pandemic, with a quarter of the study subjects being affected. Furthermore, there was a higher prevalence in the emergency department, an area where exposure to respiratory viruses is assumed to be greater. This was aggravated by the constant flow of patients with both severe and banal pathologies, such that exposure to the virus could have been gradual over time.Our study was carried out between weeks 34 and 37 of the epidemiologic year. Although the pandemic was declared in week 23, penetration of the influenza A virus at that moment was relatively low and had not reached the threshold value of previous years. From week 28 onwards, the pandemic virus was predominant throughout Spain,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> and so the workers who had previously been diagnosed with seasonal influenza had a high probability of presenting non-severe influenza A. The threshold value was exceeded in week 38, and the rising phase of the pandemic wave was verified in Spain from week 40 of 2009, and so our data predate the moment of greatest expansion of the virus.Our study population was relatively young, and in the absence of influenza symptoms presented humoral immunity levels (measured by IHA) comparable with those of the general population following the first spike of the pandemic in the United Kingdom. In the study by Miller et al.,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> the population group aged 25–44 years presented a prevalence rate of positive serology of 20.3% (95%CI: 12.5–31.2), although it should be observed that the first spike of incidence of influenza A virus had occurred prior to extraction of the samples.In our study, expansion of the virus in Spain had not even entered the rising phase of the pandemic wave, which supports the hypothesis that, at least among healthcare workers, humoral immunity was acquired, probably as a result of repeated exposure to the virus. The volunteers participating in our study had a mean age of 36 years, which excludes the possibility that the humoral immunity acquired could have been related to historical exposure to the influenza A virus, as was the case with those born before 1957.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> We also reject the hypothesis that immunity is related to prior vaccination for seasonal influenza virus, as its cross-reactivity with pandemic virus is almost non-existent.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The high seroprevalence observed is coherent with the fact that these healthcare workers did not present a higher incidence of cases of influenza A despite their presumably greater exposure, as a result of their work, because although they were more exposed, the proportion of protected subjects would also have been higher.It is noteworthy that rhinorrhoea is significantly associated with a positive serology; this is probably the expression of banal respiratory disorders, which could include infections caused by the influenza virus.When the cases with a prior diagnosis of seasonal influenza (which were very probably oligo-symptomatic influenza A) were excluded from the analysis, the professional categories in our population presenting the highest risk of being seropositive were the doctors, followed by the orderlies and the administrative staff. Although the case of the doctors could be explained by their high rate of exposure to symptomatic cases, this would not be so in the case of the administrative staff. The latter case might reflect an exposure derived simply from their presence in the hospital without having adopted special measures of protection.In this study, the participants were not selected by random sampling; we recruited volunteers, and therefore selection bias might be present. Moreover, we did not calculate a sample size beforehand, which does limit the power of our conclusions, although at the moment of designing this study there was no prior information on seroprevalence among healthcare workers, and our main goal was to compile information before the pandemic reached its peak.To date, two series of serologic studies have been published regarding healthcare workers and the influenza A pandemic. One of these studies describes seroprevalence in the context of the pandemic wave in Taiwan,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> and identified a 20% seropositive rate among healthcare workers, vs. 2.9% in the general population. There was also seen to be a higher proportion of seropositive results among workers facing the highest risk (in the emergency and infectious disease departments) vs. those at low risk. These findings are similar to those obtained from our series, although in our case the difference according to the area worked within the hospital was not so clear-cut.This second such study concerned the incidence of seroconversion among a population of healthcare workers in Singapore.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> This study reported that seroconversion is associated significantly with episodes of respiratory infections, working as a nurse and working in areas where influenza A patients are hospitalised. These findings suggest that exposure in the workplace is associated with a higher rate of seroconversion. This study, too, was carried out during the rising phrase of the pandemic wave in the region.Our study reveals the high degree of immunisation among healthcare workers before the rise of the pandemic wave in Spain. This type of study, of populations at high risk of exposure, can help contextualise the expansion of emerging viruses such as the influenza A(H1N1) virus, responsible for the 2009 pandemic.FundingProject funded by Instituto de Salud Carlos III through CIBER de Epidemiología y SaludConflict of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres151099" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec139049" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres151098" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusion" ] ] 3 => array:2 [ "identificador" => "xpalclavsec139048" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study population and time horizon" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Sample processing" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack42283" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-08-30" "fechaAceptado" => "2011-11-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec139049" "palabras" => array:6 [ 0 => "Influenza A virus" 1 => "H1N1 subtype" 2 => "Health personnel" 3 => "Haemagglutination" 4 => "Inhibition tests" 5 => "Spain" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec139048" "palabras" => array:5 [ 0 => "Virus influenza A" 1 => "Subtipo H1N1" 2 => "Personal Sanitario" 3 => "test de inhibición de la hemaglutinación" 4 => "España" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveOur aim was to study the proportion of healthcare workers with a positive serology for Influenza A(H1N1)2009 without having flu, in a Spanish hospital at the beginning of the pandemic. MethodsA survey study carried out during August 2009 (before the peak of the pandemic in Spain) in the Hospital Costa del Sol, a second level hospital with almost 300 beds in the South of Spain. The participants were workers in the following hospital units: Emergencies, Medical Area (Internal Medicine, Chest Diseases), Surgical Area (General Surgery and Anaesthesia) of any professional category. A study was made of the proportion of healthcare workers in our hospital with positive serology for the new influenza A (H1N1)2009 virus, as determined by the haemagglutination inhibition technique (≥1/40). The subjects completed a health status questionnaire, and provided a blood sample for serology testing. ResultsA total of 239 workers participated, of whom 25.1% had positive serology. The hospital area in which most individuals had positive serology was the Emergency Department (36.6%), while the professional category in which most individuals with a positive serology worked was that of the orderlies (41.7%). ConclusionAround 25% of healthcare workers in our hospital had positive serology before the peak of the pandemic, none of them had received vaccine for Influenza A (H1N1) 2009 or had been diagnosed of influenza previously." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Introducciónnuestro objetivo fue estudiar la proporción de trabajadores sanitarios con una serología positivo para Influenza A(H1N1)2009 sin haber tenido síndrome gripal, en un hospital español al comienzo de la pandemia. Métodosestudio observacional desarrollado durante Agosto de 2009 (antes del pico de la pandemia en España) en el Hospital Costa del Sol, un hospital de Segundo nivel de cerca de 300 camas en el Sur de España. Los participantes eran trabajadores de las siguientes unidades del hospital: Urgencias, Área Médica (Medicina Interna, Neumología), Área Quirúrgica (Cirugía General y Anestesia) de cualquier categoría profesional. Estudiamos la proporción de trabajadores sanitarios con serología positiva para el virus Influenza A (H1N1)2009, determinada por técnica de Inhibición de la Inmunohemaglutinación (≥1/40). Los trabajadores completaron un cuestionario de salud a la par que se les extraía una muestra de sangre para la serología. Resultadosparticiparon un total de 239 trabajadores, de los que un 25.1% presentaron serología positiva. El area del hospital con mayor porcentaje de individuos con serología positivo fue Urgencias (36.6%), mientras que la categoría profesional con mayor número de individuos positivos fueron los celadores (41.7%). Conclusionen torno a un 25% de los trabajadores sanitarios de nuestro hospital presentaron serología positivo antes del pico de la pandemia, sin que ninguno de ellos hubiera recibido la vacuna frente al virus Influenza A (H1N1)2009 o hubieran sido diagnosticados de gripe previamente." ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "See Appendix A." "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "Javier García-Alegría, Alfonso del Arco, Javier de la Torre, José Luis Prada, Miguel Marcos, Fernando Fernández, Marta Aranda, Manuel Vergara, Juan Carlos Toribio, José Antonio Rodríguez and Paola Pérez (Hospital Costa del Sol), Antonio Jesús Núñez, José Javier Santos and Francisco Pozo (Hospital de Antequera), José María Quintana, Susana García and Carlota Las Hayas (Hospital de Galdácano), Antonio Escobar, Juan Carlos Fernández and María García (Hospital de Basurto), José Ramón Sáenz, Emilio Pérez-Trallero and Diego Vicente (Hospital de Donosti), Ignacio Sánchez Arcilla, Marina Fernández y Magdalena Muedra (Hospital Ramón y Cajal), Consol Serra, Rocío Villar and Josefina Pi-Sunyer (Hospital del Mar), Pilar Varela, Victoria Oliver and Ana Vileilla (Hospital Clinic de Barcelona), Carlos Pereda and María Angeles Herrería (Hospital de Santa Bárbara), Carmen Valero, Lucía Fernández and María Angustias Romera (Hospital de Santa Ana), Pedro González and José María Jover (Complejo Hospitalario de Jaén), Manuel Zarzuela, José Gutiérrez and María Carmen Lozano (Hospital Puerta del Mar), Fernando Yélamos, Manuel Rodríguez and José Ramón Maldonado (Hospital de Torrecárdenas), María Carmen Ubago, Amelia Fernández and Dolores Torres (Hospital Virgen de las Nieves), Salvador Oña, Juan Arcos and Dolores Lerma (Hospital Materno Infantil de Málaga), David Sadia and José Bascuñana (Hospital Infanta Leonor), Berta Moyano and Elías Rodríguez (Hospital del Tajo), Francisco Martos (Facultad de Medicina, Universidad de Málaga), Antonio Daponte (Escuela Andaluza de Salud Pública), María José Pérez, Encarnación Román, Carmen Escassi and Eduardo Briones (Hospital de Valme, Sevilla), José María Mayoral (Dirección General de Salud Pública, Consejería de Salud de la Junta de Andalucía), and Mónica González Esguevillas, Isabel Pérez Grajera and Jesús María de la Fuente (Centro Nacional de Microbiología, Instituto de Salud Carlos III)." "etiqueta" => "Appendix A" "titulo" => "Work Group for the MARBEGRIP Study" "identificador" => "sec0055" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Value \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Women, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">156 (65.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, mean (95%CI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.44 (35.54–37.33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Professional category, n (%)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Doctor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 (27.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nurse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73 (30.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nursing auxiliary staff \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63 (26.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Orderly \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administrative staff \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (5.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comorbidities, n (%)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiovascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic pulmonary disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (3.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (7.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic hepatic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neuromuscular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptoms, n (%)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever (axillary temperature >37.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 (10.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rhinorrhoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (5.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sore throat \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (9.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diarrhoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (1.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Myalgia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (6.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cases in the family home, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (1.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab245222.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Principal characteristics of the study participants." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Risk factor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Odds ratio (95%CI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.28 (1.05–4.95) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hospital area</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Peripheral department \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emergencies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.26 (0.88–12.05) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.07 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medical area \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.82 (0.17–3.86) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical area \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.32 (0.29–5.81) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.71 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Professional category</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nurses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Orderlies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.01 (1.79–14.01) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administrative Staff \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.83 (1.42–16.46) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Doctors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.08 (1.48–11.22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.006 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Auxiliary Nursing Staff \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.33(0.48–11.35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rhinorrhoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.71 (1.09–12.63) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prior diagnosis of seasonal influenza \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.24 (1.32–20.82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab245223.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Results of the logistic regression analysis, including all the study participants." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Risk factor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Odds Ratio (95%CI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hospital area</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Peripheral department \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emergencies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.84 (1.04–14.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.042 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medical area \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.83 (0.17–4.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical area \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.93 (0.44–8.43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Professional category</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nurses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Orderlies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.21 (2.19–23.74) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administrative Staff \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.22 (1.79–29.06) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Doctors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.19 (2.47–27.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Auxiliary Nursing Staff \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.6 (0.66–19.53) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rhinorrhoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " 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All authors report no conflicts of interest relevant to this article" ] ] ] "idiomaDefecto" => "en" "url" => "/0213005X/0000003000000007/v1_201305090343/S0213005X11004022/v1_201305090343/en/main.assets" "Apartado" => array:4 [ "identificador" => "8591" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Originales" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/0213005X/0000003000000007/v1_201305090343/S0213005X11004022/v1_201305090343/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X11004022?idApp=UINPBA00004N"]

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Seroprevalence of antibodies to the influenza A (H1N1) virus among healthcare workers prior to the 2009 pandemic peak

Seroprevalencia de anticuerpos frente al virus influenza A(H1N1)2009 entre trabajadores sanitarios al principio de la pandemia

Julián Olallaa,b,

Corresponding author

Julio.olalla@gmail.com

Corresponding author.

, Fernando de Oryb,c, Inmaculada Casasb,d, Alfonso del Arcoa, Natalia Montiele, Francisco Rivas-Ruizf, Javier de la Torrea, José Luis Pradaa, Fernando Fernándeze, Javier García-Alegríaa, the MARBEGRIP Research Group 1

a Internal Medicine Department, Hospital Costa del Sol, Marbella, Spain

b Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP)

c Diagnostic Microbiology Service, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain

d Influenza and Respiratory Disease Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain

e Microbiology Laboratory, Hospital Costa del Sol, Marbella, Spain

f Research Unit, Hospital Costa del Sol, Marbella, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In April 2009&#44; the first cases among humans of Influenza A &#40;H1N1&#41; 2009 virus were confirmed in Mexico and the USA&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> and in June 2009&#44; a pandemic situation was declared by the World Health Organisation&#46; From the outset&#44; cases of nosocomial transmission were confirmed&#44; affecting healthcare staff&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Moreover&#44; previous experience with Severe Acute Respiratory Syndrome &#40;SARS&#41; in SE Asia<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> led researchers to believe that healthcare workers would be particularly vulnerable to the appearance of this new virus&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; the first series to be published did not show healthcare workers to be over-represented in the incidence of symptomatic cases&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is hypothesised that as a result of their greater exposure to the virus at work&#44; they acquire higher immunity than that present in the general population&#46; To date&#44; few studies have been made of seroprevalence among healthcare workers&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> and the results reported have been contradictory&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the present study&#44; we propose to determine the seroprevalence of antibodies to the influenza A virus of the 2009 pandemic among a population of healthcare workers&#46; It is hypothesised that exposure to the virus varies according to the areas of work within the hospital and according to the professional category of the worker&#44; following a gradient of greater to lesser exposure depending on the area of hospital in question &#40;Emergencies<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>Medical Area<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>Surgical Area&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study population and time horizon</span><p id="par0020" class="elsevierStylePara elsevierViewall">This transversal study was carried out at Hospital Costa del Sol in Marbella &#40;Spain&#41;&#46; The hospital has around 350 beds and serves a reference population of 372&#44;964 persons&#44; according to data from the Spanish National Statistical Institute on January 1&#44; 2009&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Participation in the study was proposed at discussions with permanent staff in of Emergency&#44; Internal Medicine and Pneumology departments &#40;medical area&#41; and General Surgery and Anaesthesia &#40;surgical area&#41;&#46; Further collaboration was provided by the emergency staff at the High Resolution Specialist Centre &#40;HARE&#41; associated with the hospital&#46; At this latter centre&#44; emergency cases are attended and short-term beds &#40;not exceeding 72<span class="elsevierStyleHsp" style=""></span>h&#41; are available&#46; According to their professional category&#44; the participating personnel were divided into doctors&#44; nurses&#44; nursing auxiliary staff&#44; orderlies and administrative staff&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The participants gave their written signed consent and completed a questionnaire on the presence or otherwise of influenza-related symptoms&#44; and comorbidities associated with a poor prognosis of influenza A&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Also included were questions on the subject&#39;s state of seasonal and pandemic influenza vaccination&#44; any cases of influenza in the immediate family&#44; daily handwashing at work and at home&#44; pharmacological treatment taken for influenza A&#44; a diagnosis of seasonal influenza or of influenza A infection &#40;the latter confirmed by PCR-positive nasal swab&#41;&#46; The main study variable was the presence of titres against the new influenza A virus &#8805;1&#47;40&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Sample collection began on 25 August 2009 and concluded on 16 September 2009&#46; This study was approved by the hospital&#39;s ethics committee&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sample processing</span><p id="par0040" class="elsevierStylePara elsevierViewall">The samples were kept in cold storage at our hospital&#44; before being sent to the National Microbiology Centre at Majadahonda &#40;Madrid&#44; Spain&#41;&#44; where they were analysed to detect antibodies against the influenza A virus responsible for the 2009 pandemic&#59; this analysis was performed using the haemagglutination inhibition technique&#44; in a modification of a method previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The antibody titres for each serum was the greatest dilution presenting inhibition of the haemagglutination power of the viral antigen&#46; Sera were considered positive with titres equal to or greater than 1&#58;40&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">A descriptive analysis was performed&#44; with measures of central tendency and dispersion for the continuous variables&#44; and of frequency distribution for the qualitative ones&#46; In the bivariate analysis&#44; the principle variable was the presence or absence of IHA&#43; &#40;&#8805;1&#47;40&#41;&#44; with the subgroups in the continuous variables being compared by means of the Mann-Whitney U test&#44; while the categoric variables were compared using the chi square test&#44; or Fisher&#39;s exact test&#44; when necessary&#44; for the qualitative ones&#46; For the IHA&#43; result variable&#44; we constructed forward selection multiple logistic regression models&#44; including the variables which in the bivariate analysis obtained <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#44; with an entry criterion of 0&#46;05 and an output criterion of 0&#46;1&#44; including the odds ratio &#40;OR&#41; values and 95&#37; confidence intervals &#40;95&#37;CI&#41;&#46; The level of statistical significance was established at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">A total of 239 healthcare workers participated in the study&#58; 113 &#40;47&#46;3&#37;&#41; worked in the emergency department&#44; 49 &#40;20&#46;5&#37;&#41; in the medical area&#44; 46 &#40;19&#46;2&#37;&#41; in the surgical area and 31 &#40;13&#37;&#41; in the emergency department of the peripheral centre associated with the hospital&#46; The principal characteristics of the participants are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; including the symptoms reported at the moment the blood sample was taken&#46; None of the participants reported suffering dyspnea&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">None of the workers were diagnosed with influenza A&#44; nor had any been vaccinated against this virus&#46; However&#44; 11 &#40;4&#46;6&#37;&#41; workers were diagnosed with seasonal influenza and 40 &#40;16&#46;7&#37;&#41; were vaccinated against seasonal influenza&#46; Only one worker was taking medication &#40;oseltamivir&#41; for this&#46; 60 &#40;25&#46;1&#37;&#41; participants presented antibody titres determined by IHA &#8805;1&#47;40&#46; The geometric mean of these values was 58&#46;56&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The proportion of positive results was significantly different among the diverse hospital departments&#58; 36&#46;6&#37; in the emergency department&#44; 12&#46;2&#37; in the medical area&#44; 22&#46;2&#37; in the surgical area and 9&#46;7&#37; in the peripheral centre associated with the hospital &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; We also observed differences by professional category&#44; with positive results among 30&#46;8&#37; of the doctors&#44; 11&#46;1&#37; of the nurses&#44; 30&#46;2&#37; of the nursing auxiliary staff&#44; 23&#46;1&#37; of the administrative staff and 41&#46;7&#37; of the orderlies &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">A positive serology was recorded among 31&#46;4&#37; of the women vs&#46; 14&#37; of the men &#40;49 females vs&#46; 12 males&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#46; There were no differences in average age between seropositive and seronegative subjects&#46; None of the comorbidities were associated with a greater prevalence of positive serologies&#46; With respect to symptoms&#44; only the presence of rhinorrhoea on the day the serology was determined and was significantly associated with a greater proportion of seropositive subjects &#40;57&#46;1&#37; vs&#46; 23&#46;3&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#46; There were no differences with respect to influenza diagnosed among other family members or whether or not vaccination against seasonal influenza had been received&#46; Of the 11 workers who had been diagnosed with seasonal influenza&#44; 6 &#40;54&#46;5&#37;&#41; presented a positive serology&#44; vs&#46; 23&#46;9&#37; of the other subjects &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#46; The geometric mean of the antibody levels in these 6 patients was higher than that of those who had not been diagnosed with seasonal influenza&#44; although without reaching statistical significance &#40;80 vs&#46; 56&#46;56&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;32&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">An initial logistic regression analysis was performed&#44; in which the outcome variable was the presentation of positive serology &#40;IHA<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#47;40&#41;&#44; and in which the independent variables were gender&#44; age&#44; the hospital area in which the worker was active&#44; professional category&#44; the presence of rhinorrhoea&#44; and the prior diagnosis of seasonal influenza&#46; The factors subsequently maintained in the model were female gender &#40;OR 2&#46;28&#44; 95&#37;CI&#58; 1&#46;05&#8211;4&#46;95&#41;&#44; rhinorrhoea &#40;OR 3&#46;71&#44; 95&#37;CI&#58; 1&#46;09&#8211;12&#46;63&#41; and prior diagnosis of influenza &#40;OR 5&#46;24&#44; 95&#37;CI&#58; 1&#46;32&#8211;20&#46;82&#41;&#44; as well as the professional categories of orderly&#44; administrative staff and doctor&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarises the results of the logistic regression analysis&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">A second model was constructed&#44; excluding the workers who had previously been diagnosed with seasonal influenza&#46; The results of this are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; In this model&#44; the factors subsequently maintained were rhinorrhoea &#40;OR of 3&#46;65&#59; 95&#37;CI&#58; 1&#46;03&#8211;12&#46;92&#41;&#44; working in the emergencies area &#40;OR of 3&#46;84&#44; 95&#37;CI&#58; 1&#46;04&#8211;14&#46;09&#41; and professional category of doctor&#44; administrative staff or orderly &#40;OR of 8&#46;19&#44; 7&#46;22 and 7&#46;21&#44; respectively&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">In our series&#44; we observed a high prevalence of healthcare workers presenting positive serology for the influenza A virus responsible for the 2009 pandemic&#44; with a quarter of the study subjects being affected&#46; Furthermore&#44; there was a higher prevalence in the emergency department&#44; an area where exposure to respiratory viruses is assumed to be greater&#46; This was aggravated by the constant flow of patients with both severe and banal pathologies&#44; such that exposure to the virus could have been gradual over time&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our study was carried out between weeks 34 and 37 of the epidemiologic year&#46; Although the pandemic was declared in week 23&#44; penetration of the influenza A virus at that moment was relatively low and had not reached the threshold value of previous years&#46; From week 28 onwards&#44; the pandemic virus was predominant throughout Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and so the workers who had previously been diagnosed with seasonal influenza had a high probability of presenting non-severe influenza A&#46; The threshold value was exceeded in week 38&#44; and the rising phase of the pandemic wave was verified in Spain from week 40 of 2009&#44; and so our data predate the moment of greatest expansion of the virus&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Our study population was relatively young&#44; and in the absence of influenza symptoms presented humoral immunity levels &#40;measured by IHA&#41; comparable with those of the general population following the first spike of the pandemic in the United Kingdom&#46; In the study by Miller et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> the population group aged 25&#8211;44 years presented a prevalence rate of positive serology of 20&#46;3&#37; &#40;95&#37;CI&#58; 12&#46;5&#8211;31&#46;2&#41;&#44; although it should be observed that the first spike of incidence of influenza A virus had occurred prior to extraction of the samples&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In our study&#44; expansion of the virus in Spain had not even entered the rising phase of the pandemic wave&#44; which supports the hypothesis that&#44; at least among healthcare workers&#44; humoral immunity was acquired&#44; probably as a result of repeated exposure to the virus&#46; The volunteers participating in our study had a mean age of 36 years&#44; which excludes the possibility that the humoral immunity acquired could have been related to historical exposure to the influenza A virus&#44; as was the case with those born before 1957&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> We also reject the hypothesis that immunity is related to prior vaccination for seasonal influenza virus&#44; as its cross-reactivity with pandemic virus is almost non-existent&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The high seroprevalence observed is coherent with the fact that these healthcare workers did not present a higher incidence of cases of influenza A despite their presumably greater exposure&#44; as a result of their work&#44; because although they were more exposed&#44; the proportion of protected subjects would also have been higher&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">It is noteworthy that rhinorrhoea is significantly associated with a positive serology&#59; this is probably the expression of banal respiratory disorders&#44; which could include infections caused by the influenza virus&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">When the cases with a prior diagnosis of seasonal influenza &#40;which were very probably oligo-symptomatic influenza A&#41; were excluded from the analysis&#44; the professional categories in our population presenting the highest risk of being seropositive were the doctors&#44; followed by the orderlies and the administrative staff&#46; Although the case of the doctors could be explained by their high rate of exposure to symptomatic cases&#44; this would not be so in the case of the administrative staff&#46; The latter case might reflect an exposure derived simply from their presence in the hospital without having adopted special measures of protection&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In this study&#44; the participants were not selected by random sampling&#59; we recruited volunteers&#44; and therefore selection bias might be present&#46; Moreover&#44; we did not calculate a sample size beforehand&#44; which does limit the power of our conclusions&#44; although at the moment of designing this study there was no prior information on seroprevalence among healthcare workers&#44; and our main goal was to compile information before the pandemic reached its peak&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">To date&#44; two series of serologic studies have been published regarding healthcare workers and the influenza A pandemic&#46; One of these studies describes seroprevalence in the context of the pandemic wave in Taiwan&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and identified a 20&#37; seropositive rate among healthcare workers&#44; vs&#46; 2&#46;9&#37; in the general population&#46; There was also seen to be a higher proportion of seropositive results among workers facing the highest risk &#40;in the emergency and infectious disease departments&#41; vs&#46; those at low risk&#46; These findings are similar to those obtained from our series&#44; although in our case the difference according to the area worked within the hospital was not so clear-cut&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">This second such study concerned the incidence of seroconversion among a population of healthcare workers in Singapore&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This study reported that seroconversion is associated significantly with episodes of respiratory infections&#44; working as a nurse and working in areas where influenza A patients are hospitalised&#46; These findings suggest that exposure in the workplace is associated with a higher rate of seroconversion&#46; This study&#44; too&#44; was carried out during the rising phrase of the pandemic wave in the region&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Our study reveals the high degree of immunisation among healthcare workers before the rise of the pandemic wave in Spain&#46; This type of study&#44; of populations at high risk of exposure&#44; can help contextualise the expansion of emerging viruses such as the influenza A&#40;H1N1&#41; virus&#44; responsible for the 2009 pandemic&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">Project funded by Instituto de Salud Carlos III through CIBER de Epidemiolog&#237;a y Salud</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2011-08-30"
    "fechaAceptado" => "2011-11-20"
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            0 => "Influenza A virus"
            1 => "H1N1 subtype"
            2 => "Health personnel"
            3 => "Haemagglutination"
            4 => "Inhibition tests"
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            0 => "Virus influenza A"
            1 => "Subtipo H1N1"
            2 => "Personal Sanitario"
            3 => "test de inhibici&#243;n de la hemaglutinaci&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Our aim was to study the proportion of healthcare workers with a positive serology for Influenza A&#40;H1N1&#41;2009 without having flu&#44; in a Spanish hospital at the beginning of the pandemic&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A survey study carried out during August 2009 &#40;before the peak of the pandemic in Spain&#41; in the Hospital Costa del Sol&#44; a second level hospital with almost 300 beds in the South of Spain&#46; The participants were workers in the following hospital units&#58; Emergencies&#44; Medical Area &#40;Internal Medicine&#44; Chest Diseases&#41;&#44; Surgical Area &#40;General Surgery and Anaesthesia&#41; of any professional category&#46; A study was made of the proportion of healthcare workers in our hospital with positive serology for the new influenza A &#40;H1N1&#41;2009 virus&#44; as determined by the haemagglutination inhibition technique &#40;&#8805;1&#47;40&#41;&#46; The subjects completed a health status questionnaire&#44; and provided a blood sample for serology testing&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 239 workers participated&#44; of whom 25&#46;1&#37; had positive serology&#46; The hospital area in which most individuals had positive serology was the Emergency Department &#40;36&#46;6&#37;&#41;&#44; while the professional category in which most individuals with a positive serology worked was that of the orderlies &#40;41&#46;7&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Around 25&#37; of healthcare workers in our hospital had positive serology before the peak of the pandemic&#44; none of them had received vaccine for Influenza A &#40;H1N1&#41; 2009 or had been diagnosed of influenza previously&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">nuestro objetivo fue estudiar la proporci&#243;n de trabajadores sanitarios con una serolog&#237;a positivo para Influenza A&#40;H1N1&#41;2009 sin haber tenido s&#237;ndrome gripal&#44; en un hospital espa&#241;ol al comienzo de la pandemia&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">estudio observacional desarrollado durante Agosto de 2009 &#40;antes del pico de la pandemia en Espa&#241;a&#41; en el Hospital Costa del Sol&#44; un hospital de Segundo nivel de cerca de 300 camas en el Sur de Espa&#241;a&#46; Los participantes eran trabajadores de las siguientes unidades del hospital&#58; Urgencias&#44; &#193;rea M&#233;dica &#40;Medicina Interna&#44; Neumolog&#237;a&#41;&#44; &#193;rea Quir&#250;rgica &#40;Cirug&#237;a General y Anestesia&#41; de cualquier categor&#237;a profesional&#46; Estudiamos la proporci&#243;n de trabajadores sanitarios con serolog&#237;a positiva para el virus Influenza A &#40;H1N1&#41;2009&#44; determinada por t&#233;cnica de Inhibici&#243;n de la Inmunohemaglutinaci&#243;n &#40;&#8805;1&#47;40&#41;&#46; Los trabajadores completaron un cuestionario de salud a la par que se les extra&#237;a una muestra de sangre para la serolog&#237;a&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">participaron un total de 239 trabajadores&#44; de los que un 25&#46;1&#37; presentaron serolog&#237;a positiva&#46; El area del hospital con mayor porcentaje de individuos con serolog&#237;a positivo fue Urgencias &#40;36&#46;6&#37;&#41;&#44; mientras que la categor&#237;a profesional con mayor n&#250;mero de individuos positivos fueron los celadores &#40;41&#46;7&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">en torno a un 25&#37; de los trabajadores sanitarios de nuestro hospital presentaron serolog&#237;a positivo antes del pico de la pandemia&#44; sin que ninguno de ellos hubiera recibido la vacuna frente al virus Influenza A &#40;H1N1&#41;2009 o hubieran sido diagnosticados de gripe previamente&#46;</p>"
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            "apendice" => "<p id="par0160" class="elsevierStylePara elsevierViewall">Javier Garc&#237;a-Alegr&#237;a&#44; Alfonso del Arco&#44; Javier de la Torre&#44; Jos&#233; Luis Prada&#44; Miguel Marcos&#44; Fernando Fern&#225;ndez&#44; Marta Aranda&#44; Manuel Vergara&#44; Juan Carlos Toribio&#44; Jos&#233; Antonio Rodr&#237;guez and Paola P&#233;rez &#40;Hospital Costa del Sol&#41;&#44; Antonio Jes&#250;s N&#250;&#241;ez&#44; Jos&#233; Javier Santos and Francisco Pozo &#40;Hospital de Antequera&#41;&#44; Jos&#233; Mar&#237;a Quintana&#44; Susana Garc&#237;a and Carlota Las Hayas &#40;Hospital de Gald&#225;cano&#41;&#44; Antonio Escobar&#44; Juan Carlos Fern&#225;ndez and Mar&#237;a Garc&#237;a &#40;Hospital de Basurto&#41;&#44; Jos&#233; Ram&#243;n S&#225;enz&#44; Emilio P&#233;rez-Trallero and Diego Vicente &#40;Hospital de Donosti&#41;&#44; Ignacio S&#225;nchez Arcilla&#44; Marina Fern&#225;ndez y Magdalena Muedra &#40;Hospital Ram&#243;n y Cajal&#41;&#44; Consol Serra&#44; Roc&#237;o Villar and Josefina Pi-Sunyer &#40;Hospital del Mar&#41;&#44; Pilar Varela&#44; Victoria Oliver and Ana Vileilla &#40;Hospital Clinic de Barcelona&#41;&#44; Carlos Pereda and Mar&#237;a Angeles Herrer&#237;a &#40;Hospital de Santa B&#225;rbara&#41;&#44; Carmen Valero&#44; Luc&#237;a Fern&#225;ndez and Mar&#237;a Angustias Romera &#40;Hospital de Santa Ana&#41;&#44; Pedro Gonz&#225;lez and Jos&#233; Mar&#237;a Jover &#40;Complejo Hospitalario de Ja&#233;n&#41;&#44; Manuel Zarzuela&#44; Jos&#233; Guti&#233;rrez and Mar&#237;a Carmen Lozano &#40;Hospital Puerta del Mar&#41;&#44; Fernando Y&#233;lamos&#44; Manuel Rodr&#237;guez and Jos&#233; Ram&#243;n Maldonado &#40;Hospital de Torrec&#225;rdenas&#41;&#44; Mar&#237;a Carmen Ubago&#44; Amelia Fern&#225;ndez and Dolores Torres &#40;Hospital Virgen de las Nieves&#41;&#44; Salvador O&#241;a&#44; Juan Arcos and Dolores Lerma &#40;Hospital Materno Infantil de M&#225;laga&#41;&#44; David Sadia and Jos&#233; Bascu&#241;ana &#40;Hospital Infanta Leonor&#41;&#44; Berta Moyano and El&#237;as Rodr&#237;guez &#40;Hospital del Tajo&#41;&#44; Francisco Martos &#40;Facultad de Medicina&#44; Universidad de M&#225;laga&#41;&#44; Antonio Daponte &#40;Escuela Andaluza de Salud P&#250;blica&#41;&#44; Mar&#237;a Jos&#233; P&#233;rez&#44; Encarnaci&#243;n Rom&#225;n&#44; Carmen Escassi and Eduardo Briones &#40;Hospital de Valme&#44; Sevilla&#41;&#44; Jos&#233; Mar&#237;a Mayoral &#40;Direcci&#243;n General de Salud P&#250;blica&#44; Consejer&#237;a de Salud de la Junta de Andaluc&#237;a&#41;&#44; and M&#243;nica Gonz&#225;lez Esguevillas&#44; Isabel P&#233;rez Grajera and Jes&#250;s Mar&#237;a de la Fuente &#40;Centro Nacional de Microbiolog&#237;a&#44; Instituto de Salud Carlos III&#41;&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Work Group for the MARBEGRIP Study"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Administrative staff&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbidities&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiovascular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chronic pulmonary disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;7&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chronic hepatic disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neuromuscular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Symptoms&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fever &#40;axillary temperature &#62;37&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cough&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;10&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rhinorrhoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sore throat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;9&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diarrhoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Myalgia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;6&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cases in the family home&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Risk factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Odds ratio &#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;28 &#40;1&#46;05&#8211;4&#46;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;04&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Peripheral department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Emergencies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;26 &#40;0&#46;88&#8211;12&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Medical area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;82 &#40;0&#46;17&#8211;3&#46;86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Surgical area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;32 &#40;0&#46;29&#8211;5&#46;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Professional category</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nurses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;21 &#40;2&#46;19&#8211;23&#46;74&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;22 &#40;1&#46;79&#8211;29&#46;06&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#46;19 &#40;2&#46;47&#8211;27&#46;12&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Auxiliary Nursing Staff&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;6 &#40;0&#46;66&#8211;19&#46;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;65 &#40;1&#46;03&#8211;12&#46;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;045&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Update&#58; swine influenza A &#40;H1N1&#41; infections &#8211; California and Texas&#44; April 2009"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Morb Mortal Wkly Rep"
                        "fecha" => "2009"
                        "volumen" => "58"
                        "paginaInicial" => "435"
                        "paginaFinal" => "437"
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                      "titulo" => "Emergence of a novel swine-origin influenza A &#40;H1N1&#41; virus in humans"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46;S&#46; Dawood"
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                            2 => "L&#46; Finelli"
                            3 => "M&#46;W&#46; Shaw"
                            4 => "S&#46; Lindstrom"
                            5 => "R&#46;J&#46; Garten"
                          ]
                        ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa0903810"
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                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2009"
                        "volumen" => "360"
                        "paginaInicial" => "2605"
                        "paginaFinal" => "2615"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19423869"
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                      "titulo" => "Pandemic potential of a strain of influenza A &#40;H1N1&#41;&#58; early findings"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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Article information

ISSN: 0213005X
Original language: English

DOI:10.1016/j.eimc.2011.11.019

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2024 October	12	0	12
2024 September	17	7	24
2024 August	15	4	19
2024 July	10	1	11
2024 June	14	3	17
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2024 January	11	1	12
2023 December	14	2	16
2023 November	11	2	13
2023 October	12	2	14
2023 September	12	3	15
2023 August	4	2	6
2023 July	10	4	14
2023 June	9	3	12
2023 May	21	6	27
2023 April	10	1	11
2023 March	8	2	10
2023 February	12	11	23
2023 January	18	3	21
2022 December	16	6	22
2022 November	17	14	31
2022 October	17	5	22
2022 September	20	17	37
2022 August	22	22	44
2022 July	15	6	21
2022 June	18	8	26
2022 May	12	4	16
2022 April	16	17	33
2022 March	21	9	30
2022 February	16	5	21
2022 January	10	8	18
2021 December	14	12	26
2021 November	11	5	16
2021 October	46	15	61
2021 September	12	15	27
2021 August	17	5	22
2021 July	21	6	27
2021 June	13	9	22
2021 May	13	9	22
2021 April	24	22	46
2021 March	14	5	19
2021 February	20	4	24
2021 January	19	9	28
2020 December	12	7	19
2020 November	14	4	18
2020 October	16	5	21
2020 September	25	9	34
2020 August	17	1	18
2020 July	10	9	19
2020 June	11	4	15
2020 May	26	9	35
2020 April	21	9	30
2020 March	20	0	20
2020 February	14	7	21
2020 January	17	9	26
2019 December	14	6	20
2019 November	3	2	5
2019 October	4	5	9
2019 September	6	1	7
2019 August	11	3	14
2019 July	12	19	31
2019 June	21	37	58
2019 May	105	32	137
2019 April	26	9	35
2019 March	2	4	6
2019 February	7	7	14
2019 January	6	4	10
2018 December	10	4	14
2018 November	13	11	24
2018 October	13	0	13
2018 September	9	8	17
2018 August	10	4	14
2018 July	6	0	6
2018 June	3	2	5
2018 May	3	1	4
2018 April	6	2	8
2018 March	7	1	8
2018 February	6	1	7
2018 January	4	0	4
2017 December	11	0	11
2017 November	11	1	12
2017 October	10	3	13
2017 September	10	2	12
2017 August	25	2	27
2017 July	12	3	15
2017 June	11	2	13
2017 May	9	3	12
2017 April	18	6	24
2017 March	5	9	14
2017 February	12	1	13
2017 January	23	1	24
2016 December	20	4	24
2016 November	27	0	27
2016 October	47	5	52
2016 September	21	2	23
2016 August	25	3	28
2016 July	27	4	31
2016 June	25	5	30
2016 May	11	15	26
2016 April	9	2	11
2016 March	14	10	24
2016 February	26	12	38
2016 January	22	15	37
2015 December	26	8	34
2015 November	15	7	22
2015 October	22	5	27
2015 September	17	2	19
2015 August	13	4	17
2015 July	18	5	23
2015 June	4	1	5
2015 May	23	6	29
2015 April	8	8	16
2015 March	19	5	24
2015 February	9	1	10
2015 January	25	6	31
2014 December	45	4	49
2014 November	35	0	35
2014 October	54	6	60
2014 September	35	1	36
2014 August	32	3	35
2014 July	47	2	49
2014 June	37	0	37
2014 May	39	3	42
2014 April	20	0	20
2014 March	35	7	42
2014 February	36	6	42
2014 January	36	10	46
2013 December	36	7	43
2013 November	33	10	43
2013 October	45	7	52
2013 September	41	10	51
2013 August	40	8	48
2013 July	35	7	42
2013 June	10	1	11
2013 May	9	8	17
2013 April	16	5	21
2013 March	18	13	31
2013 February	8	4	12
2013 January	7	3	10
2012 December	3	2	5
2012 November	4	6	10
2012 October	5	6	11
2012 September	6	6	12
2012 July	551	0	551

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