Measles outbreak related to healthcare transmission

array:22 ["pii" => "S157698872030042X" "issn" => "15769887" "doi" => "10.1016/j.vacun.2020.08.002" "estado" => "S300" "fechaPublicacion" => "2021-01-01" "aid" => "161" "copyrightAnyo" => "2020" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Vacunas. 2021;22:20-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S1576988720300728" "issn" => "15769887" "doi" => "10.1016/j.vacun.2020.12.001" "estado" => "S300" "fechaPublicacion" => "2021-01-01" "aid" => "175" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Vacunas. 2021;22:28-38" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "Parálisis flácida aguda y enterovirus en España. Resultados de la vigilancia en 2019" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "28" "paginaFinal" => "38" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Acute flaccid paralysis and enterovirus in Spain. Results from 2019 surveillance" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1354 "Ancho" => 2167 "Tamanyo" => 207891 ] ] "descripcion" => array:1 [ "es" => "Calidad en el estudio de muestras: toma de muestras en los 14 días siguientes al inicio de la parálisis. España, 1999-2019." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. López-Perea, J. Masa-Calles, M. Cabrerizo, V. Gallardo-García, C. Malo, N. Torner, C. Izquierdo, C. Marín, M. García Cenoz, C. Muñoz-Almagro, I. Huerta, M. Portell, A. Blasco, M.L. Rojo, S. García-Hernández, H. Marcos, J.M. Ramos, I. Losada, A. Nieto Juliá, V. García-Ortúzar, F. González Carril, A. Blanco, A. Rivas, D. Castrillejo, S. Sanbonmatsu, J.M. Navarro, C. Pérez-González, N. Rabella, M. del Cuerpo, A. Moreno-Docón, A. Navascués, S. Pérez-Castro, M.P. Romero, M. Aranzamendi, A. Martínez-Sapiña" "autores" => array:35 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "López-Perea" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Masa-Calles" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Cabrerizo" ] 3 => array:2 [ "nombre" => "V." "apellidos" => "Gallardo-García" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Malo" ] 5 => array:2 [ "nombre" => "N." "apellidos" => "Torner" ] 6 => array:2 [ "nombre" => "C." "apellidos" => "Izquierdo" ] 7 => array:2 [ "nombre" => "C." "apellidos" => "Marín" ] 8 => array:2 [ "nombre" => "M." "apellidos" => "García Cenoz" ] 9 => array:2 [ "nombre" => "C." "apellidos" => "Muñoz-Almagro" ] 10 => array:2 [ "nombre" => "I." "apellidos" => "Huerta" ] 11 => array:2 [ "nombre" => "M." "apellidos" => "Portell" ] 12 => array:2 [ "nombre" => "A." "apellidos" => "Blasco" ] 13 => array:2 [ "nombre" => "M.L." "apellidos" => "Rojo" ] 14 => array:2 [ "nombre" => "S." "apellidos" => "García-Hernández" ] 15 => array:2 [ "nombre" => "H." "apellidos" => "Marcos" ] 16 => array:2 [ "nombre" => "J.M." "apellidos" => "Ramos" ] 17 => array:2 [ "nombre" => "I." "apellidos" => "Losada" ] 18 => array:2 [ "nombre" => "A." "apellidos" => "Nieto Juliá" ] 19 => array:2 [ "nombre" => "V." "apellidos" => "García-Ortúzar" ] 20 => array:2 [ "nombre" => "F." "apellidos" => "González Carril" ] 21 => array:2 [ "nombre" => "A." "apellidos" => "Blanco" ] 22 => array:2 [ "nombre" => "A." "apellidos" => "Rivas" ] 23 => array:2 [ "nombre" => "D." "apellidos" => "Castrillejo" ] 24 => array:2 [ "nombre" => "S." "apellidos" => "Sanbonmatsu" ] 25 => array:2 [ "nombre" => "J.M." "apellidos" => "Navarro" ] 26 => array:2 [ "nombre" => "C." "apellidos" => "Pérez-González" ] 27 => array:2 [ "nombre" => "N." "apellidos" => "Rabella" ] 28 => array:2 [ "nombre" => "M." "apellidos" => "del Cuerpo" ] 29 => array:2 [ "nombre" => "A." "apellidos" => "Moreno-Docón" ] 30 => array:2 [ "nombre" => "A." "apellidos" => "Navascués" ] 31 => array:2 [ "nombre" => "S." "apellidos" => "Pérez-Castro" ] 32 => array:2 [ "nombre" => "M.P." "apellidos" => "Romero" ] 33 => array:2 [ "nombre" => "M." "apellidos" => "Aranzamendi" ] 34 => array:2 [ "nombre" => "A." "apellidos" => "Martínez-Sapiña" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1576988720300728?idApp=UINPBA00004N" "url" => "/15769887/0000002200000001/v2_202106031157/S1576988720300728/v2_202106031157/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S1576988720300431" "issn" => "15769887" "doi" => "10.1016/j.vacun.2020.08.003" "estado" => "S300" "fechaPublicacion" => "2021-01-01" "aid" => "162" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Vacunas. 2021;22:10-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Epidemic trends of COVID-19 in 10 countries compared with Turkey" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "10" "paginaFinal" => "19" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tendencias epidémicas en los diez principales países con más casos de COVID-19 en comparación con Turquía" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0035" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1187 "Ancho" => 2500 "Tamanyo" => 180511 ] ] "descripcion" => array:1 [ "en" => "The number of confirmed deaths due to COVID-19 and recovered patients (as of April 25, 2020)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "V. Durmuş" "autores" => array:1 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Durmuş" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1576988720300431?idApp=UINPBA00004N" "url" => "/15769887/0000002200000001/v2_202106031157/S1576988720300431/v2_202106031157/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Measles outbreak related to healthcare transmission" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "20" "paginaFinal" => "27" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "N. Torner, J. Ferràs, L. Curto, J. Rebull, J. Sol, J. Costa, M.M. Mosquera, C. Izquierdo, A. Martínez, M. Jané" "autores" => array:10 [ 0 => array:3 [ "nombre" => "N." "apellidos" => "Torner" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:4 [ "nombre" => "J." "apellidos" => "Ferràs" "email" => array:1 [ 0 => "joaquim.ferras@gencat.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Curto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Rebull" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Sol" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "J." "apellidos" => "Costa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 6 => array:3 [ "nombre" => "M.M." "apellidos" => "Mosquera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 7 => array:3 [ "nombre" => "C." "apellidos" => "Izquierdo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 8 => array:3 [ "nombre" => "A." "apellidos" => "Martínez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 9 => array:3 [ "nombre" => "M." "apellidos" => "Jané" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "CIBER Epidemiolgy and Public Health (CIBERESP), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Public Health Agency of Catalonia, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Preventive Medicine and Public Health, Hospital Tortosa Verge de la Cinta, Tortosa, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Occupational Medicine, Basic Preventive Unit, Institut Català de la Salut-Terres de l’Ebre, Tortosa, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Microbiology Department, Hospital Clínic, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Brote de sarampión relacionado con trasmisión en centro sanitario" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: CNE informe annual MMR 2018." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2537 "Ancho" => 2167 "Tamanyo" => 483456 ] ] "descripcion" => array:1 [ "en" => "Phylogenetic tree of N450 sequences of strain haplotype/variants circulating in Spain in 2018." ] ] ] "textoCompleto" => "IntroductionMeasles is one of the most contagious diseases of humans and therefore it has a high transmission rate among susceptible populations. Although case fatality rate is 1 death per 1000 cases, it is frequently associated to complications such as pneumonia, encephalitis, diarrhea, otitis media and subacute sclerosing pan encephalitis, being the later a very rare though severe complication.<a class="elsevierStyleCrossRef" href="#bib0155">1</a> Vaccination against measles is the main tool for prevention and control of measles disease burden. Measles is a vaccine-preventable disease that has greatly decreased it's incidence since the measles, mumps and rubella (MMR) vaccine was introduced in Catalonia to the childhood immunization schedule in 1981, and since 1988 has been offered as a two doses scheme, the first dose at 12–15 months of age and the second at 11years of age and since 1999 at 4 years of age.<a class="elsevierStyleCrossRefs" href="#bib0160">2,3</a> Vaccination coverage with MMR vaccine has been increasing since 1999 with the first dose coverage exceeding 95% and 92% for the second dose in 2018.<a class="elsevierStyleCrossRefs" href="#bib0170">4,5</a> MMR is considered a highly effective vaccine for preventing measles, one dose of the MMR vaccine is considered to be 95% effective at preventing measles infection and 92% effective at preventing the spread of measles to contacts.<a class="elsevierStyleCrossRef" href="#bib0180">6</a> Measles virus (MV) outbreaks and incidence peaks occur during late winter and early spring in areas where the circulation of the virus is endemic and immunization coverage with MCV are low. Recently there has been a surge of outbreaks in countries where MV circulation is considered interrupted.<a class="elsevierStyleCrossRef" href="#bib0185">7</a> Before the introduction of monovalent MCV in 1963, major epidemics occurred approximately every 2–3 years and it is estimated that 30 million cases of measles and more than 2 million deaths occurred globally each year, and that by the age of 15 years, more than 95% of individuals had been infected with MV. The live attenuated MCV vaccine used today for immunization against measles induces both humoral and cellular immune responses and protects against infection with all genotypes of MV.<a class="elsevierStyleCrossRefs" href="#bib0190">8,9</a>Even in countries with high vaccination rates, maintaining vaccine uptake is critically important to prevent reestablishment of endemic transmission and to protect individuals from imported transmission. Health care professionals play an important role in vaccine uptake as well as in prevention of measles spread during outbreaks.<a class="elsevierStyleCrossRef" href="#bib0200">10</a>The aim of this study is to describe a measles outbreak in a highly immunized community and the implication of a health care facility in the transmission of the disease.MethodsCase investigation and outbreak responseDescriptive observational prospective study of a measles outbreak linked to hospital setting with sociodemographic, clinical, virological and immunization variables studied.Study population: Cases suspected of measles reported to the sub-directorate of surveillance and response to Public Health emergencies of the Public Health Agency of Catalonia from 28th of March to 6th of June of 2018. The geographical location of the outbreak was in the Southeastern region of Catalonia by the Ebro River delta (Terres de l’Ebre Health Region), with a population of 177,000 inhabitants.Studied variables from suspected cases were age, gender, measles immunization status, date of rash onset, clinical presentation, laboratory sampling and results, background concerning international or national travel, and attendance to healthcare facility 3 weeks before rash onset and during transmission period (4 days before and 4 days after onset of rash).Clinical case definition adopted was any person with fever and maculopapular rash and cough, coryza or conjunctivitis. Cases were classified as confirmed if clinical case definition was met and there was laboratory confirmation or direct epidemiologic linkage to a case confirmed by one of the methods describe for laboratory confirmation.Laboratory confirmation was considered when there was either detection of measles-virus specific nucleic acid from urine and/or pharyngeal swab using real time reverse polymerase chain reaction (RT-PCR); or IgG seroconversion, or a four-fold rise in measles immunoglobulin G antibody titer; or positive serologic test for specific measles immunoglobulin M (IgM) antibody in the absence of immunization the previous two weeks. Collection of urine and/or pharyngeal specimens at <10 days and blood samples between 3 and 30 days of rash onset.Genotyping of positive RT-PCR samples was performed by nucleotidic sequencing of the genomic fragment followed by phylogenetic analysis of the N-450 sequences.<a class="elsevierStyleCrossRef" href="#bib0205">11</a>Statistical analysis of category variables, the chi2 test was used, the exact Fisher test for non-parametric data and z test to compare proportions. Setting a statistical significance level of p<0.05. Odds ratio (OR) is calculated with its confidence intervals (IC).ResultsOutbreak descriptive epidemiologyMeasles outbreak was reported to the Terres de l’Ebre surveillance unit in Tortosa (Tarragona) on March 28th. The first confirmed case was reported on March 22nd and corresponded to a 41-year-old unvaccinated non-health worker from the Hospital de Tortosa Verge de la Cinta, who had viral rash onset on March 19th.The second case was not reported until a week later, a 33-year-old unvaccinated non-healthcare worker from the same hospital who had rash onset on March 20th.Over the following 5 weeks there were a total of 47 suspected cases reported in the Terres de l’Ebre health region of Catalonia (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) of these, 14 were confirmed as measles cases (13 laboratory confirmed and 1 epidemiologically linked to a laboratory confirmed case). Genotype B3 MVs/Dublin.IRL/8.16-variant was obtained from 6 (46.2%) of the laboratory confirmed cases studied. Two cases (14.3%) were admitted at the hospital, there was no severe complication and they were discharged after a short stay (2 and 4 days) Eight cases (57.14%) were men and median age of confirmed cases was 33 years (range 16–46) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>All unvaccinated cases presented fever and rash while clinical presentation of vaccinated cases. In this outbreak, one vaccinated case did not present rash, and the other three vaccinated cases did not present classic symptoms such as conjunctivitis, cough or Koplik enanthema. None of the cases presented severe complications. Clinical presentation and complications of cases is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Laboratory results of 2 dose MCV immunized cases is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Hospital associated transmission was confirmed in 13/14 (93%) cases of which 8 (61.5%) were hospital staff. Five cases (38.5%) were healthcare workers, three (23%) non-healthcare workers and 6 were patients who attended the facility. Only four cases (28.5%) were immunized with 2 doses of MCV [2 (25%) men vs 2 (33.3%) women (p=0.156) (OR 0.17 95%CI 0.02–1.72)]. 3 (75%) of the vaccinated cases were healthcare workers.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Among the unvaccinated cases, two siblings had not received the vaccine because of parental decision. The eight remaining unvaccinated cases were born before 1981 when MCV was introduced to the systematic immunization schedule in Catalonia, of these 3 (37.5%) were non-healthcare hospital workers (cleaning/maintenance)No statistical difference was observed among hospital staff and community cases as to immunization status (OR 2.4 95%CI: 0.17–32.88; p=0.49).Susceptible contacts of confirmed cases were isolated until the transmission period passed and if the contacts were healthcare workers, in coordination with the hospital's Preventive Medicine and Occupational Health Service, they were excluded from work.The immune status of household and other contacts of cases was reviewed and according to protocol, those not immunized were vaccinated. Contact tracing of direct contacts of confirmed cases were carried out at least for 21 days after the last exposure to the case.HCW measles immunization verificationAccording to the National Surveillance Network guidelines (RENAVE), active monitoring and monitoring of immune status among primary and hospital health workers was carried out from the hospital's Preventive Medicine and Occupational Health Department.<a class="elsevierStyleCrossRef" href="#bib0170">4</a>Registered serologic evidence of immunity or of receipt of MCV. Hospital staff without evidence of measles immunity had blood samples drawn for serological testing and were offered MMR vaccination (1–2 doses 28 days apart if needed to complete vaccination scheme). Sixteen healthcare workers identified as contacts of confirmed cases and who tested negative or were not able to provide evidence of immunity were immunized and excluded from work. A high level of protection was found for more than 95% of the staff and all other unprotected or low measles IgG titles were vaccinated. Workers who had fever or could not prove vaccination or having passed the disease were excluded from work 21 days after last exposure.The occupational health services of hospital-linked external companies were also instructed to carry out active monitoring of their workers.Exposure and contact investigationsThe search for the index case was carried out by reviewing the medical discharge records of all patients presenting with fever and rash, who attended the emergency room service of the hospital between the 5th and 7th of March. The index case was a patient that presented with a fever and rash of 24h on March 7th (date of rash onset March 6th), and had been diagnosed as scarlet fever. Another case had also had contact with the first at the ER when accompanying a relative on the same day, 7th of March. This contact was confirmed by PCR and genotype variant was identified as B3 MVs/Dublin.IRL/8.16-variant (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). At the time of identification of the suspected index case, although recovered, blood sample was collected and sent to the measles, mumps and rubella reference laboratory of Catalonia at the Clinical Hospital of Barcelona. Although nearly two months had passed, serology resulted positive for IgM Measles specific antibodies confirming the case. This index case's background revealed that, from February 18th to 20th he had been visiting a relative admitted at the Hospital La Fe in Valencia where a measles outbreak was active. The study of the genotype variant of the measles virus determined that the Tortosa hospital outbreak derived from a case infected in the La Fe hospital in Valencia and therefore derived from the same transmission chain as the outbreak reported in Valencia late in 2017 and which was active until July 2018.<a class="elsevierStyleCrossRef" href="#bib0210">12</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>After two maximum incubation periods (42 days) from the date of rash onset of the last confirmed case on April 24th the outbreak was declared interrupted on June 6th 2018.DiscussionDespite high MCV coverage, there are measles immunity gaps, which can enhance transmission among young adults and specially HCWs.<a class="elsevierStyleCrossRefs" href="#bib0215">13,14</a> In highly communicable infectious diseases such as measles, it is very important to carry out epidemiological research in the shortest possible time, so as cases are reported, the epidemiological investigation has to be initiated. The first two cases reported were hospital employees, but the following three cases did not have a clear link to the hospital. However, it was important to try to find out a missed case, which would have initiated the local transmission chain. Epidemiological evidence drove to the conclusion that the index case had to correspond to an individual attended at the emergency room (ER) and that had misdiagnosed. Through the review of the cases and their circumstances it was inferred that the search had to be focused on patients who had only occasionally visited the hospital, rather than hospital employees because of the difficulty to establish the time of the exposure of the latter. A link was found for a case who had been at the ER accompanying a relative, on March 7th, the same day the suspected index case had been misdiagnosed, in the ER, as scarlet fever. The index case was a 41-year-old man, who had been visiting a relative admitted at the Hospital La Fe in Valencia from February 18th to 20th when a large measles outbreak was taking place at the facility. There was spread to the community by this case linked to the index case, with transmission to four other cases in nearby municipality. This fact focuses on the importance of detecting suspected measles for any patient attended for fever and rash in order to establish isolation measures immediately and prevent nosocomial transmission.<a class="elsevierStyleCrossRef" href="#bib0225">15</a>Having been able to collect samples and determine MV genotype haplotype/variant from 8 of the 14 cases from the outbreak allowed to prove that they belonged to the same chain of transmission as the outbreak occurring in the Hospital at Valencia.<a class="elsevierStyleCrossRefs" href="#bib0210">12,16,17</a>Still there was a case detected retrospectively in May, by the laboratory reporting of an IgM positive serology in a nurse who presented fever and rash on March 23rd, but unlike the index case, this case did not cause any secondary transmission. Although there was no registered immunization evidence, she might have received an MMR dose at 11 years of age at school in 1990.<a class="elsevierStyleCrossRef" href="#bib0160">2</a> This could explain why despite the delay in contact tracing due to delay in reporting as a measles case, reduced transmissibility in vaccinated cases was responsible for the lack of transmission. Laboratory results for three of the four 2 MCV dose vaccinated cases point at a lower viral charge with either urine and or pharyngeal specimens reporting negative to PCR testing. This could also be an indication of lower transmissibility in immunized cases. A recent study carried out in the United States by Gastañaduy et al. found that unvaccinated patients with measles are approximately 3–4 times more Infectious compared with those cases vaccinated with one or two doses of MCV.<a class="elsevierStyleCrossRef" href="#bib0240">18</a>This is an outbreak were the hospital facility has been the main source of infection of measles to mostly unvaccinated population while working, consulting or visiting It is important to ensure that all HCWs have presumptive evidence of measles immunity, either because of a registered immunization with two dose MCV or laboratory confirmed immunity by positive titer of IgG against measles.<a class="elsevierStyleCrossRef" href="#bib0245">19</a> Current hiring policies for hospital facility employees should take into account all employees, not only, HCW as far as screening and immunization concerns. In this outbreak, this was carried out as a prevention and control measure in the context of the outbreak. Although hospital employees did not sustain transmission, it is highly important to underscore the need and cost-effectiveness of immunization with MCV to any health care facility employee, whether they be health care workers, students, administration or maintenance employees.<a class="elsevierStyleCrossRefs" href="#bib0250">20,21</a>Clinical presentation of cases might not be typical, especially in young adults who have received one or two doses of MCV, therefore clinicians should be alert and suspect measles in any patient consulting for rash and fever. In this outbreak, only one vaccinated case did not present rash, yet 75% of them did not present classic symptoms such as conjunctivitis, cough or Koplik enanthema.The linkage of the measles outbreak in Tortosa to the same chain of transmission of the Valencia outbreak of imported origin from Romania was identified being the isolated viruses a B3 MVs/Dublin.IRL/8.16-variant.The outbreak allowed immune status revision of primary and hospital care network professionals in the area and updating vaccination according to serological data obtained.After suffering the infection, immunity in people lasts a lifetime, while immunity conferred by the vaccine can present a proportion equal to or less than 5% that might have primary or secondary vaccine failure. Waning of antibody protection after a few years has also been established as a possible cause of measles outbreaks in geographical areas where wild measles virus circulation is scarce and due to importations. This would be one of the possible explanations for the contagion among the cases that were correctly vaccinated. Atypical clinical presentation of symptoms was also found in some of these cases. This fact has been observed in several studies and seems to become more frequent in adult cases.<a class="elsevierStyleCrossRefs" href="#bib0260">22–28</a>Except for the two unvaccinated siblings, no other secondary cases of transmission occurred. This, along with the fact that the virus circulated intensely during the first few weeks, indicates that there is a high level of immunity among the population of Tortosa and surrounding areas. However, susceptible population groups were found to be those unvaccinated because of their age.The main limitation to this study is the small sample size which impairs statistical analysis of the data on clinical presentation, complications and laboratory results, yet it information deployed is relevant to implement more inclusive immunization policies for all personnel related to healthcare institutions as well as a higher sensitivity when suspecting measles at emergency room triage.The outbreak was contained to few cases<a class="elsevierStyleCrossRef" href="#bib0220">14</a> due to high immunization coverage in the population, prompt implementation of surveillance and control measures. Nonetheless, a higher immunization coverage of healthcare related personnel, other non-health professionals who are related to these facilities with high risk of contagion, has to be achieved and maintained in order to avoid nosocomial transmission and the economic impact of outbreaks on the institutions affected<a class="elsevierStyleCrossRef" href="#bib0295">29</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The unvaccinated population cohorts born before MMR vaccine was included in childhood immunization schedule also has to be consider as candidates for increased coverage. The outbreak also raised awareness, updated clinical knowledge on measles among the healthcare workers, and triggered them to be alert as to possible new outbreaks.Suspecting measles in cases presenting with exanthema and fever, allows for immediate airborne isolation, and retrieving measles immunity records for healthcare facility employees and contacts. Such measures are of utmost importance in preventing health care-associated transmission and in minimizing hospital outbreak spillover to the community.<a class="elsevierStyleCrossRefs" href="#bib0245">19,30</a>Ethical issuesAnalysis of data and samples were performed under the epidemiologic surveillance of vaccine preventable diseases established for Public Health Surveillance purposes, there is no need for individual signed consent.Financial disclosureNo funding received.Conflict of interestN. Torner is member of the editorial team of the journal. Other authors declare there is no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1519856" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1378169" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1519855" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1378168" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Case investigation and outbreak response" ] ] ] 6 => array:3 [ "identificador" => "sec0020" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Outbreak descriptive epidemiology" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "HCW measles immunization verification" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Exposure and contact investigations" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Ethical issues" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Financial disclosure" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack534017" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-03-30" "fechaAceptado" => "2020-08-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1378169" "palabras" => array:4 [ 0 => "Measles" 1 => "Outbreak" 2 => "Nosocomial transmission" 3 => "Immunization" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1378168" "palabras" => array:4 [ 0 => "Sarampión" 1 => "Brote epidémico" 2 => "Transmisión nosocomial" 3 => "Inmunización" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionMeasles has a high transmission rate among susceptible populations. Healthcare facilities can play an important role in measles transmission. The aim of this study is to describe a measles outbreak in a highly immunized community and the implication of healthcare workers in the transmission of the disease. MethodsDescriptive study of measles outbreak linked to hospital setting with sociodemographic, clinical, virological and immunization variables studied. Cases were confirmed by RT-PCR in clinical specimens and genotyped by nucleotide sequencing. Association was assessed by chi2, Fisher's exact and z test. Statistical significance at p=0.05. Results47 suspected measles cases were reported from March to June 2018 at Terres de l’Ebre, Catalonia. Fourteen cases were confirmed, 8 cases (57%) were men; median age of cases 33y (range 16–46 y). Hospital associated transmission was confirmed in 13 (93%) cases, 8 (61.5%) were hospital staff. Five (38.5%) were healthcare workers (HCW), three (23%) non-healthcare workers (non-HCW) and 6 (46%) were patients attended at the hospital. Four cases (28.5%) were immunized with 2 doses of measles virus containing vaccine (MCV); 3 (75%) were HCW. No statistical difference observed among hospital staff and community cases as to immunization (OR 2.4 95%CI: 0.17–32.88; p=0.49). Genotype B3 MVs/Dublin.IRL/8.16-variant was obtained from confirmed cases. ConclusionSuspecting measles diagnosis, allows for immediate airborne isolation, and retrieving measles immunity records for healthcare facility employees and contacts. Vaccination of HCW and the adoption of good infection control will minimize nosocomial transmission and spreading of the virus to the community." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl sarampión tiene una elevada tasa de transmisión entre poblaciones susceptibles. Los centros sanitarios pueden desempeñar un papel importante en la transmisión del sarampión. El objetivo de este estudio es describir un brote de sarampión en una población con elevada cobertura de inmunización y la implicación de los trabajadores sanitarios en la transmisión de la enfermedad. MétodosEstudio descriptivo de un brote de sarampión vinculado al entorno hospitalario. Se estudiaron variables sociodemográficas, clínicas, virológicas y de estado vacunal de los casos. Se confirmaron los casos por RT-PCR en muestras clínicas y posterior genotipado por secuenciación nucleotídica. Análisis estadístico mediante χ2, prueba exacta de Fisher y test z; nivel de significación estadística p<0,05. ResultadosDe marzo a junio de 2018 se notificaron un total de 47 casos sospechosos de sarampión en Terres de l’Ebre, Cataluña (España). Hubo 14 casos, y 8 (57%) eran hombres; mediana de edad, 33años (rango 16-46años). Se confirmó transmisión hospitalaria en 13 (93%) de los casos; 8 (61,5%) eran personal hospitalario. Cinco (38,5%) eran personal sanitario (PS), 3 (23%) Pno-S y 6 (46%) eran pacientes del hospital. Cuatro (28,5%) estaban vacunados con 2 dosis de vacuna antisarampión (TV), 3 de los cuales (75%) eran PS. No se observó diferencia significativa entre personal hospitalario y casos comunitarios sobre estado vacunal (OR: 2,4; IC95%: 0,17-32,88; p=0,49). Se identificó genotipo B3 MVs/Dublin.IRL/8.16-variant en los casos confirmados por PCR. ConclusiónLa sospecha de sarampión como diagnóstico permite el aislamiento inmediato de los casos y la revisión del estado vacunal frente al sarampión de personal y contactos de los centros sanitarios. La vacunación del personal sanitario y el seguimiento de buenas prácticas de control y prevención de la infección permiten disminuir el riesgo de transmisión nosocomial, así como la diseminación del virus y su repercusión en la comunidad." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1584 "Ancho" => 2917 "Tamanyo" => 298217 ] ] "descripcion" => array:1 [ "en" => "Distribution of reported cases (confirmed and discarded cases) according to day of rash onset (n=47)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1244 "Ancho" => 2167 "Tamanyo" => 110551 ] ] "descripcion" => array:1 [ "en" => "Distribution of confirmed cases according to age group and gender. n=14." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: CNE informe annual MMR 2018." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2537 "Ancho" => 2167 "Tamanyo" => 483456 ] ] "descripcion" => array:1 [ "en" => "Phylogenetic tree of N450 sequences of strain haplotype/variants circulating in Spain in 2018." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "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"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total number of cases (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Unvaccinated cases (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vaccinated cases (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></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="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptoms</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rash \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">13 (92.9%) \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">10 (100%) \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 (75%) \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">0.622 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever \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 (100%) \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">10 (100%) \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 (100%) \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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coryza \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 (28.6%) \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 (20%) \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 (50%) \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">0.640 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " 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">6 (42.9%) \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">5 (50%) \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 (25%) \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">0.798 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conjunctivitis \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 (21.4%) \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 (20%) \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 (25%) \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">0.607 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Koplik enanthema \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 (21.4%) \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 (20%) \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 (25%) \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">0.607 \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="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complications</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Otitis media \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 (0%) \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 (0%) \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 (0%) \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">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diarreas \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 (7.1%) \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 (10%) \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 (0%) \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">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nausea/vomitus \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 (21.4%) \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 (20%) \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 (25%) \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">0.607 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Faringitis/tonsilitis \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 (14.2%) \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 (10%) \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 (25%) \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">0.904 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Joint pain \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 (7.1%) \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 (10%) \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 (0%) \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">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headache \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 (7.1%) \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 (10%) \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 (0%) \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">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Encefalitis \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 (0%) \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 (0%) \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 (0%) \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">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pneumonia \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 (0%) \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 (0%) \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 (0%) \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">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2610057.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical presentation and complications of cases according to immunization status." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "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"><th 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" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MMR timingFirst/second dose \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Urine PCR \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pharyngeal swabPCR \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Serum IgM antibody detection \t\t\t\t\t\t\n \t\t\t\t\t\t</th></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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \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">1999/2003 \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">Positive \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">Positive \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">– \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \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">1993/1999 \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">Positive \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">Negative \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">Positive \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \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">2000/2002 \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">Negative \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">Negative \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">Positive \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \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">1985/1989/1995<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \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">Negative \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">Positive \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">Low titer \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2610056.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Hospital staff, immunized at staff enrollment." ] ] ] "descripcion" => array:1 [ "en" => "Distribution of MMR measles immunization, first and second dose, and laboratory results of cases immunized with 2 dose MCV." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Measles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "W.J. Moss" 1 => "D.E. Griffin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(10)62352-5" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2012" "volumen" => "379" "paginaInicial" => "153" "paginaFinal" => "164" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21855993" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0160" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Generalitat de Catalunya. Departament de Salut. L’eliminació del xarampió a Catalunya per a l’any 2000. Bases científiques i programa. Barcelona; 1999. (Quaderns de Salut Pública). Report No.: 12. Available from: <a target="_blank" href="http://canalsalut.gencat.cat/web/.content/_A-Z/X/xarampio/arxius/eliminacioxarampio.pdf">http://canalsalut.gencat.cat/web/.content/_A-Z/X/xarampio/arxius/eliminacioxarampio.pdf</a>." ] ] ] 2 => array:3 [ "identificador" => "bib0165" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estado inmunitario de la población española frente a las enfermedades inmunoprevenibles mediante vacunaciones sistemáticas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Salleras" 1 => "N. Soldevila" 2 => "A. Domínguez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Vacunas" "fecha" => "2015" "volumen" => "16" "paginaInicial" => "18" "paginaFinal" => "33" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0170" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Centro Nacional de Epidemiología. Protocolos de la Red Nacional de Vigilancia Epidemiológica. Madrid; 2015. Available from: <a target="_blank" href="https://publicaciones.isciii.es/">https://publicaciones.isciii.es/</a>." ] ] ] 4 => array:3 [ "identificador" => "bib0175" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ministerio de Sanidad consumo y bienestar social; Direcciión general de Salud Pública Coberturas vacunales en España. Madrid. 2019. Available from: <a target="_blank" href="https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/CoberturasVacunacion/Todas_las_tablas.pdf">https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/CoberturasVacunacion/Todas_las_tablas.pdf#page=12020</a> [cited June 30]." ] ] ] 5 => array:3 [ "identificador" => "bib0180" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vaccines for measles, mumps and rubella in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "V. Demicheli" 1 => "A. Rivetti" 2 => "M.G. Debalini" 3 => "C. Di Pietrantonj" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD004407.pub3" "Revista" => array:2 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2012" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0185" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Measles and measles vaccination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.C. Bester" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamapediatrics.2016.1787" "Revista" => array:5 [ "tituloSerie" => "JAMA Pediatr" "fecha" => "2016" "volumen" => "170" "paginaInicial" => "1209" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27695849" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0190" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Measles vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.E. Griffin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1089/vim.2017.0143" "Revista" => array:6 [ "tituloSerie" => "Viral Immunol" "fecha" => "2018" "volumen" => "31" "paginaInicial" => "86" "paginaFinal" => "95" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29256824" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0195" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Genetic characterization of measles vaccine strains" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "B. Bankamp" 1 => "M. Takeda" 2 => "Y. Zhang" 3 => "W. Xu" 4 => "P.A. Rota" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/infdis/jir097" "Revista" => array:7 [ "tituloSerie" => "J Infect Dis" "fecha" => "2011" "volumen" => "204" "numero" => "Suppl. 1" "paginaInicial" => "S533" "paginaFinal" => "S548" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21666210" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0200" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Children and adolescents unvaccinated against measles: geographic clustering, parents’ beliefs, and missed opportunities" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P.J. Smith" 1 => "E.K. Marcuse" 2 => "J.F. Seward" 3 => "Z. Zhao" 4 => "W.A. Orenstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/003335491513000512" "Revista" => array:6 [ "tituloSerie" => "Public Health Rep" "fecha" => "2015" "volumen" => "130" "paginaInicial" => "485" "paginaFinal" => "504" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26327727" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0205" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Measles virus genotype circulation in Spain after implementation of the national measles elimination plan 2001–2003" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.M. Mosquera" 1 => "F. Ory" 2 => "de" 3 => "J.E. Echevarría" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/jmv.20248" "Revista" => array:6 [ "tituloSerie" => "J Med Virol" "fecha" => "2005" "volumen" => "75" "paginaInicial" => "137" "paginaFinal" => "146" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15543577" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0210" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Instituto de Salud Carlos III. CIBERESP y Ministerio de Sanidad Consumo y Bienestar Social. Plan de Eliminación del Sarampión y Rubeola, España 2018. 2019." ] ] ] 12 => array:3 [ "identificador" => "bib0215" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ongoing outbreak with well over 4,000 measles cases in Italy from January to end August 2017 – what is making elimination so difficult?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Filia" 1 => "A. Bella" 2 => "M. Del Manso" 3 => "M. Baggieri" 4 => "F. Magurano" 5 => "M.C. Rota" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2807/1560-7917.ES.2017.22.37.30614" "Revista" => array:5 [ "tituloSerie" => "Eurosurveillance" "fecha" => "2017" "volumen" => "22" "paginaInicial" => "30614" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28933342" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0220" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Workplace vaccination against measles in a teaching hospital of Rome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. Coppeta" 1 => "A. Pietroiusti" 2 => "L. Morucci" 3 => "A. Neri" 4 => "M. Ferraro" 5 => "A. Magrini" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jhin.2018.11.022" "Revista" => array:6 [ "tituloSerie" => "J Hosp Infect" "fecha" => "2019" "volumen" => "101" "paginaInicial" => "364" "paginaFinal" => "365" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30529439" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0225" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "World Health Organization W. Guide for clinical case management and infection prevention and control during a measles outbreak. Geneva: WHO; 2020. 34 p. Available from: <a target="_blank" href="https://apps.who.int/iris/bitstream/handle/10665/331599/9789240002869-eng.pdf?sequence=1%26isAllowed=y">https://apps.who.int/iris/bitstream/handle/10665/331599/9789240002869-eng.pdf?sequence=1&isAllowed=y</a>." ] ] ] 15 => array:3 [ "identificador" => "bib0230" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Tran T, Kostecki R, Catton M, Druce J. Utility of a stressed single nucleotide polymorphism (SNP) real-time PCR assay for rapid identification of measles vaccine strains in patient samples. Tang Y-W, editor. J Clin Microbiol. 2018;56. Available from: <a target="_blank" href="http://jcm.asm.org/lookup/doi/10.1128/JCM.00360-18">http://jcm.asm.org/lookup/doi/10.1128/JCM.00360-18</a>." ] ] ] 16 => array:3 [ "identificador" => "bib0235" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The importance of serological and molecular analyses for the diagnosis of measles cases and for meeting elimination targets in Turkey from 2007 to 2015" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Cosgun" 1 => "D. Guldemir" 2 => "A. Coskun" 3 => "S. Yolbakan" 4 => "A.T. Kalaycioglu" 5 => "G. Korukluoglu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1017/S0950268818000432" "Revista" => array:6 [ "tituloSerie" => "Epidemiol Infect" "fecha" => "2018" "volumen" => "146" "paginaInicial" => "735" "paginaFinal" => "740" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29534775" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0240" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Factors associated with measles transmission in the United States during the postelimination era" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.A. Gastañaduy" 1 => "S. Funk" 2 => "B.A. Lopman" 3 => "P.A. Rota" 4 => "M. Gambhir" 5 => "B. Grenfell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamapediatrics.2019.4357" "Revista" => array:5 [ "tituloSerie" => "JAMA Pediatr" "fecha" => "2020" "volumen" => "174" "paginaInicial" => "56" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31738391" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0245" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "World Health Organization W. Guide for clinical case management and infection prevention and control during a measles outbreak Geneve; 2020 34 (Institutional Repository for Information Series IRIS). Available from: <a target="_blank" href="https://apps.who.int/iris/handle/10665/331599">https://apps.who.int/iris/handle/10665/331599</a>." ] ] ] 19 => array:3 [ "identificador" => "bib0250" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cost-effectiveness of workplace vaccination against measles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L. Coppeta" 1 => "L. Morucci" 2 => "A. Pietroiusti" 3 => "A. Magrini" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/21645515.2019.1616505" "Revista" => array:6 [ "tituloSerie" => "Hum Vaccin Immunother" "fecha" => "2019" "volumen" => "15" "paginaInicial" => "2847" "paginaFinal" => "2850" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31339463" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0255" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Measles, rubella, mumps, and varicella seroprevalence among health care workers in Turkey: is prevaccination screening cost-effective?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Celikbas" 1 => "O. Ergonul" 2 => "S. Aksaray" 3 => "N. Tuygun" 4 => "H. Esener" 5 => "G. Tanır" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajic.2006.04.213" "Revista" => array:6 [ "tituloSerie" => "Am J Infect Control" "fecha" => "2006" "volumen" => "34" "paginaInicial" => "583" "paginaFinal" => "587" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17097453" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0260" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Amoroso A, editor. Fever with rash in a healthy adult. Clin Infect Dis. 2016;62:1021. Available from: <a target="_blank" href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciw062">https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciw062</a>." ] ] ] 22 => array:3 [ "identificador" => "bib0265" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Modified measles with an atypical presentation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.M. Uren" 1 => "B.R. Vasant" 2 => "D. Judd" 3 => "D.F. Looke" 4 => "A.J. Henderson" 5 => "K.A. Jarvinen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Commun Dis Intell" "fecha" => "2019" "volumen" => "17" "paginaInicial" => "43" ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0270" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recognizing measles mumps, and rubella in the emergency department" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Gadler" 1 => "N. Martinez" 2 => "J. Ogg-Gress" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/TME.0000000000000190" "Revista" => array:6 [ "tituloSerie" => "Adv Emerg Nurs J" "fecha" => "2018" "volumen" => "40" "paginaInicial" => "110" "paginaFinal" => "118" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29715253" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0275" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fever and rash: revisiting measles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.R. Barbosa" 1 => "A.S. Martins" 2 => "J. Ruivo" 3 => "L. Carvalho" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.20344/amp.9776" "Revista" => array:5 [ "tituloSerie" => "Acta Med Port" "fecha" => "2018" "volumen" => "31" "paginaInicial" => "341" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30020880" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0280" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Viral exanthems: an update on laboratory testing of the adult patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.M. Korman" 1 => "A. Alikhan" 2 => "B.H. Kaffenberger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2016.08.034" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2017" "volumen" => "76" "paginaInicial" => "538" "paginaFinal" => "550" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28413059" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0285" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atypical measles syndrome in adults: still around" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Melenotte" 1 => "N. Cassir" 2 => "L. Tessonnier" 3 => "P. Brouqui" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2015" ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0290" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A forty-four year-old immunized woman with maculopapular and petechial rash diagnosed as measles: an extremely rare presentation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Sali" 1 => "A. Yazdani" 2 => "Z. Doosti" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Int J Infect" "fecha" => "2018" "volumen" => "5" ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0295" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Measles among healthcare workers in Italy: is it time to act?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V. Baccolini" 1 => "A. Sindoni" 2 => "G. Adamo" 3 => "A. Rosso" 4 => "A. Massimi" 5 => "A. Bella" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Hum Vaccin Immunother" "fecha" => "2020" "volumen" => "25" "paginaInicial" => "1" "paginaFinal" => "10" ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0300" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Health care-associated measles outbreak in the United States after an importation: challenges and economic impact" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.Y. Chen" 1 => "S. Anderson" 2 => "P.K. Kutty" 3 => "F. Lugo" 4 => "M. McDonald" 5 => "P.A. Rota" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/infdis/jir115" "Revista" => array:7 [ "tituloSerie" => "J Infect Dis" "fecha" => "2011" "volumen" => "203" "paginaInicial" => "1517" "paginaFinal" => "1525" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21531693" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1474442218302394" "estado" => "S300" "issn" => "14744422" ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack534017" "titulo" => "Acknowledgements" "texto" => "We thank the collaboration of Josefa Masa Calles and Noemi Lopez Perea (Enfermedades Inmunoprevenibles. CIBERESP, Centro Nacional de Epidemiología Instituto de Salud Carlos III, Madrid) and the reporting physicians of the hospital and primary care centers of the Terres de l’Ebre Health Region." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15769887/0000002200000001/v2_202106031157/S157698872030042X/v2_202106031157/en/main.assets" "Apartado" => array:4 [ "identificador" => "10130" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Originales" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/15769887/0000002200000001/v2_202106031157/S157698872030042X/v2_202106031157/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157698872030042X?idApp=UINPBA00004N"]

Statistics

Original article

Measles outbreak related to healthcare transmission

Brote de sarampión relacionado con trasmisión en centro sanitario

N. Tornera,b, J. Ferràsb,

Corresponding author

joaquim.ferras@gencat.cat

Corresponding author.

, L. Curtob, J. Rebullc, J. Sold, J. Costae, M.M. Mosquerae, C. Izquierdob, A. Martíneza,b, M. Janéa,b

a CIBER Epidemiolgy and Public Health (CIBERESP), Spain

b Public Health Agency of Catalonia, Barcelona, Spain

c Department of Preventive Medicine and Public Health, Hospital Tortosa Verge de la Cinta, Tortosa, Spain

d Occupational Medicine, Basic Preventive Unit, Institut Català de la Salut-Terres de l’Ebre, Tortosa, Spain

e Microbiology Department, Hospital Clínic, Barcelona, Spain

Read

260

Times
was read the article

Total PDF

181

Total HTML

Share statistics

 array:22 [
  "pii" => "S157698872030042X"
  "issn" => "15769887"
  "doi" => "10.1016/j.vacun.2020.08.002"
  "estado" => "S300"
  "fechaPublicacion" => "2021-01-01"
  "aid" => "161"
  "copyrightAnyo" => "2020"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "fla"
  "cita" => "Vacunas. 2021;22:20-7"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:1 [
    "total" => 0
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S1576988720300728"
    "issn" => "15769887"
    "doi" => "10.1016/j.vacun.2020.12.001"
    "estado" => "S300"
    "fechaPublicacion" => "2021-01-01"
    "aid" => "175"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Vacunas. 2021;22:28-38"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "es" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original</span>"
      "titulo" => "Par&#225;lisis fl&#225;cida aguda y enterovirus en Espa&#241;a&#46; Resultados de la vigilancia en 2019"
      "tienePdf" => "es"
      "tieneTextoCompleto" => "es"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "28"
          "paginaFinal" => "38"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Acute flaccid paralysis and enterovirus in Spain&#46; Results from 2019 surveillance"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "es" => true
      ]
      "contienePdf" => array:1 [
        "es" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0020"
          "etiqueta" => "Figura 4"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr4.jpeg"
              "Alto" => 1354
              "Ancho" => 2167
              "Tamanyo" => 207891
            ]
          ]
          "descripcion" => array:1 [
            "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Calidad en el estudio de muestras&#58; toma de muestras en los 14 d&#237;as siguientes al inicio de la par&#225;lisis&#46; Espa&#241;a&#44; 1999-2019&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "N&#46; L&#243;pez-Perea, J&#46; Masa-Calles, M&#46; Cabrerizo, V&#46; Gallardo-Garc&#237;a, C&#46; Malo, N&#46; Torner, C&#46; Izquierdo, C&#46; Mar&#237;n, M&#46; Garc&#237;a Cenoz, C&#46; Mu&#241;oz-Almagro, I&#46; Huerta, M&#46; Portell, A&#46; Blasco, M&#46;L&#46; Rojo, S&#46; Garc&#237;a-Hern&#225;ndez, H&#46; Marcos, J&#46;M&#46; Ramos, I&#46; Losada, A&#46; Nieto Juli&#225;, V&#46; Garc&#237;a-Ort&#250;zar, F&#46; Gonz&#225;lez Carril, A&#46; Blanco, A&#46; Rivas, D&#46; Castrillejo, S&#46; Sanbonmatsu, J&#46;M&#46; Navarro, C&#46; P&#233;rez-Gonz&#225;lez, N&#46; Rabella, M&#46; del Cuerpo, A&#46; Moreno-Doc&#243;n, A&#46; Navascu&#233;s, S&#46; P&#233;rez-Castro, M&#46;P&#46; Romero, M&#46; Aranzamendi, A&#46; Mart&#237;nez-Sapi&#241;a"
          "autores" => array:35 [
            0 => array:2 [
              "nombre" => "N&#46;"
              "apellidos" => "L&#243;pez-Perea"
            ]
            1 => array:2 [
              "nombre" => "J&#46;"
              "apellidos" => "Masa-Calles"
            ]
            2 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "Cabrerizo"
            ]
            3 => array:2 [
              "nombre" => "V&#46;"
              "apellidos" => "Gallardo-Garc&#237;a"
            ]
            4 => array:2 [
              "nombre" => "C&#46;"
              "apellidos" => "Malo"
            ]
            5 => array:2 [
              "nombre" => "N&#46;"
              "apellidos" => "Torner"
            ]
            6 => array:2 [
              "nombre" => "C&#46;"
              "apellidos" => "Izquierdo"
            ]
            7 => array:2 [
              "nombre" => "C&#46;"
              "apellidos" => "Mar&#237;n"
            ]
            8 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "Garc&#237;a Cenoz"
            ]
            9 => array:2 [
              "nombre" => "C&#46;"
              "apellidos" => "Mu&#241;oz-Almagro"
            ]
            10 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "Huerta"
            ]
            11 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "Portell"
            ]
            12 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Blasco"
            ]
            13 => array:2 [
              "nombre" => "M&#46;L&#46;"
              "apellidos" => "Rojo"
            ]
            14 => array:2 [
              "nombre" => "S&#46;"
              "apellidos" => "Garc&#237;a-Hern&#225;ndez"
            ]
            15 => array:2 [
              "nombre" => "H&#46;"
              "apellidos" => "Marcos"
            ]
            16 => array:2 [
              "nombre" => "J&#46;M&#46;"
              "apellidos" => "Ramos"
            ]
            17 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "Losada"
            ]
            18 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Nieto Juli&#225;"
            ]
            19 => array:2 [
              "nombre" => "V&#46;"
              "apellidos" => "Garc&#237;a-Ort&#250;zar"
            ]
            20 => array:2 [
              "nombre" => "F&#46;"
              "apellidos" => "Gonz&#225;lez Carril"
            ]
            21 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Blanco"
            ]
            22 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Rivas"
            ]
            23 => array:2 [
              "nombre" => "D&#46;"
              "apellidos" => "Castrillejo"
            ]
            24 => array:2 [
              "nombre" => "S&#46;"
              "apellidos" => "Sanbonmatsu"
            ]
            25 => array:2 [
              "nombre" => "J&#46;M&#46;"
              "apellidos" => "Navarro"
            ]
            26 => array:2 [
              "nombre" => "C&#46;"
              "apellidos" => "P&#233;rez-Gonz&#225;lez"
            ]
            27 => array:2 [
              "nombre" => "N&#46;"
              "apellidos" => "Rabella"
            ]
            28 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "del Cuerpo"
            ]
            29 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Moreno-Doc&#243;n"
            ]
            30 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Navascu&#233;s"
            ]
            31 => array:2 [
              "nombre" => "S&#46;"
              "apellidos" => "P&#233;rez-Castro"
            ]
            32 => array:2 [
              "nombre" => "M&#46;P&#46;"
              "apellidos" => "Romero"
            ]
            33 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "Aranzamendi"
            ]
            34 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Mart&#237;nez-Sapi&#241;a"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "es"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1576988720300728?idApp=UINPBA00004N"
    "url" => "/15769887/0000002200000001/v2_202106031157/S1576988720300728/v2_202106031157/es/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S1576988720300431"
    "issn" => "15769887"
    "doi" => "10.1016/j.vacun.2020.08.003"
    "estado" => "S300"
    "fechaPublicacion" => "2021-01-01"
    "aid" => "162"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Vacunas. 2021;22:10-9"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
      "titulo" => "Epidemic trends of COVID-19 in 10 countries compared with Turkey"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "10"
          "paginaFinal" => "19"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Tendencias epid&#233;micas en los diez principales pa&#237;ses con m&#225;s casos de COVID-19 en comparaci&#243;n con Turqu&#237;a"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0035"
          "etiqueta" => "Fig&#46; 7"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr7.jpeg"
              "Alto" => 1187
              "Ancho" => 2500
              "Tamanyo" => 180511
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The number of confirmed deaths due to COVID-19 and recovered patients &#40;as of April 25&#44; 2020&#41;&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "V&#46; Durmu&#351;"
          "autores" => array:1 [
            0 => array:2 [
              "nombre" => "V&#46;"
              "apellidos" => "Durmu&#351;"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1576988720300431?idApp=UINPBA00004N"
    "url" => "/15769887/0000002200000001/v2_202106031157/S1576988720300431/v2_202106031157/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
    "titulo" => "Measles outbreak related to healthcare transmission"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "20"
        "paginaFinal" => "27"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "N&#46; Torner, J&#46; Ferr&#224;s, L&#46; Curto, J&#46; Rebull, J&#46; Sol, J&#46; Costa, M&#46;M&#46; Mosquera, C&#46; Izquierdo, A&#46; Mart&#237;nez, M&#46; Jan&#233;"
        "autores" => array:10 [
          0 => array:3 [
            "nombre" => "N&#46;"
            "apellidos" => "Torner"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          1 => array:4 [
            "nombre" => "J&#46;"
            "apellidos" => "Ferr&#224;s"
            "email" => array:1 [
              0 => "joaquim.ferras@gencat.cat"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "L&#46;"
            "apellidos" => "Curto"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "J&#46;"
            "apellidos" => "Rebull"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "J&#46;"
            "apellidos" => "Sol"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "J&#46;"
            "apellidos" => "Costa"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "M&#46;M&#46;"
            "apellidos" => "Mosquera"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
            ]
          ]
          7 => array:3 [
            "nombre" => "C&#46;"
            "apellidos" => "Izquierdo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          8 => array:3 [
            "nombre" => "A&#46;"
            "apellidos" => "Mart&#237;nez"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          9 => array:3 [
            "nombre" => "M&#46;"
            "apellidos" => "Jan&#233;"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:5 [
          0 => array:3 [
            "entidad" => "CIBER Epidemiolgy and Public Health &#40;CIBERESP&#41;&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Public Health Agency of Catalonia&#44; Barcelona&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Department of Preventive Medicine and Public Health&#44; Hospital Tortosa Verge de la Cinta&#44; Tortosa&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Occupational Medicine&#44; Basic Preventive Unit&#44; Institut Catal&#224; de la Salut-Terres de l&#8217;Ebre&#44; Tortosa&#44; Spain"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Microbiology Department&#44; Hospital Cl&#237;nic&#44; Barcelona&#44; Spain"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Brote de sarampi&#243;n relacionado con trasmisi&#243;n en centro sanitario"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; CNE informe annual MMR 2018&#46;"
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 2537
            "Ancho" => 2167
            "Tamanyo" => 483456
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Phylogenetic tree of N450 sequences of strain haplotype&#47;variants circulating in Spain in 2018&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Measles is one of the most contagious diseases of humans and therefore it has a high transmission rate among susceptible populations&#46; Although case fatality rate is 1 death per 1000 cases&#44; it is frequently associated to complications such as pneumonia&#44; encephalitis&#44; diarrhea&#44; otitis media and subacute sclerosing pan encephalitis&#44; being the later a very rare though severe complication&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Vaccination against measles is the main tool for prevention and control of measles disease burden&#46; Measles is a vaccine-preventable disease that has greatly decreased it&#39;s incidence since the measles&#44; mumps and rubella &#40;MMR&#41; vaccine was introduced in Catalonia to the childhood immunization schedule in 1981&#44; and since 1988 has been offered as a two doses scheme&#44; the first dose at 12&#8211;15 months of age and the second at 11years of age and since 1999 at 4 years of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2&#44;3</span></a> Vaccination coverage with MMR vaccine has been increasing since 1999 with the first dose coverage exceeding 95&#37; and 92&#37; for the second dose in 2018&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;5</span></a> MMR is considered a highly effective vaccine for preventing measles&#44; one dose of the MMR vaccine is considered to be 95&#37; effective at preventing measles infection and 92&#37; effective at preventing the spread of measles to contacts&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> Measles virus &#40;MV&#41; outbreaks and incidence peaks occur during late winter and early spring in areas where the circulation of the virus is endemic and immunization coverage with MCV are low&#46; Recently there has been a surge of outbreaks in countries where MV circulation is considered interrupted&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> Before the introduction of monovalent MCV in 1963&#44; major epidemics occurred approximately every 2&#8211;3 years and it is estimated that 30 million cases of measles and more than 2 million deaths occurred globally each year&#44; and that by the age of 15 years&#44; more than 95&#37; of individuals had been infected with MV&#46; The live attenuated MCV vaccine used today for immunization against measles induces both humoral and cellular immune responses and protects against infection with all genotypes of MV&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Even in countries with high vaccination rates&#44; maintaining vaccine uptake is critically important to prevent reestablishment of endemic transmission and to protect individuals from imported transmission&#46; Health care professionals play an important role in vaccine uptake as well as in prevention of measles spread during outbreaks&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study is to describe a measles outbreak in a highly immunized community and the implication of a health care facility in the transmission of the disease&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Case investigation and outbreak response</span><p id="par0020" class="elsevierStylePara elsevierViewall">Descriptive observational prospective study of a measles outbreak linked to hospital setting with sociodemographic&#44; clinical&#44; virological and immunization variables studied&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Study population&#58; Cases suspected of measles reported to the sub-directorate of surveillance and response to Public Health emergencies of the Public Health Agency of Catalonia from 28th of March to 6th of June of 2018&#46; The geographical location of the outbreak was in the Southeastern region of Catalonia by the Ebro River delta &#40;Terres de l&#8217;Ebre Health Region&#41;&#44; with a population of 177&#44;000 inhabitants&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Studied variables from suspected cases were age&#44; gender&#44; measles immunization status&#44; date of rash onset&#44; clinical presentation&#44; laboratory sampling and results&#44; background concerning international or national travel&#44; and attendance to healthcare facility 3 weeks before rash onset and during transmission period &#40;4 days before and 4 days after onset of rash&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinical case definition adopted was any person with fever and maculopapular rash and cough&#44; coryza or conjunctivitis&#46; Cases were classified as confirmed if clinical case definition was met and there was laboratory confirmation or direct epidemiologic linkage to a case confirmed by one of the methods describe for laboratory confirmation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Laboratory confirmation was considered when there was either detection of measles-virus specific nucleic acid from urine and&#47;or pharyngeal swab using real time reverse polymerase chain reaction &#40;RT-PCR&#41;&#59; or IgG seroconversion&#44; or a four-fold rise in measles immunoglobulin G antibody titer&#59; or positive serologic test for specific measles immunoglobulin M &#40;IgM&#41; antibody in the absence of immunization the previous two weeks&#46; Collection of urine and&#47;or pharyngeal specimens at &#60;10 days and blood samples between 3 and 30 days of rash onset&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Genotyping of positive RT-PCR samples was performed by nucleotidic sequencing of the genomic fragment followed by phylogenetic analysis of the N-450 sequences&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Statistical analysis of category variables&#44; the chi<span class="elsevierStyleSup">2</span> test was used&#44; the exact Fisher test for non-parametric data and z test to compare proportions&#46; Setting a statistical significance level of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46; Odds ratio &#40;OR&#41; is calculated with its confidence intervals &#40;IC&#41;&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Outbreak descriptive epidemiology</span><p id="par0055" class="elsevierStylePara elsevierViewall">Measles outbreak was reported to the Terres de l&#8217;Ebre surveillance unit in Tortosa &#40;Tarragona&#41; on March 28th&#46; The first confirmed case was reported on March 22nd and corresponded to a 41-year-old unvaccinated non-health worker from the Hospital de Tortosa Verge de la Cinta&#44; who had viral rash onset on March 19th&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The second case was not reported until a week later&#44; a 33-year-old unvaccinated non-healthcare worker from the same hospital who had rash onset on March 20th&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Over the following 5 weeks there were a total of 47 suspected cases reported in the Terres de l&#8217;Ebre health region of Catalonia &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; of these&#44; 14 were confirmed as measles cases &#40;13 laboratory confirmed and 1 epidemiologically linked to a laboratory confirmed case&#41;&#46; Genotype B3 MVs&#47;Dublin&#46;IRL&#47;8&#46;16-variant was obtained from 6 &#40;46&#46;2&#37;&#41; of the laboratory confirmed cases studied&#46; Two cases &#40;14&#46;3&#37;&#41; were admitted at the hospital&#44; there was no severe complication and they were discharged after a short stay &#40;2 and 4 days&#41; Eight cases &#40;57&#46;14&#37;&#41; were men and median age of confirmed cases was 33 years &#40;range 16&#8211;46&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">All unvaccinated cases presented fever and rash while clinical presentation of vaccinated cases&#46; In this outbreak&#44; one vaccinated case did not present rash&#44; and the other three vaccinated cases did not present classic symptoms such as conjunctivitis&#44; cough or Koplik enanthema&#46; None of the cases presented severe complications&#46; Clinical presentation and complications of cases is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Laboratory results of 2 dose MCV immunized cases is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Hospital associated transmission was confirmed in 13&#47;14 &#40;93&#37;&#41; cases of which 8 &#40;61&#46;5&#37;&#41; were hospital staff&#46; Five cases &#40;38&#46;5&#37;&#41; were healthcare workers&#44; three &#40;23&#37;&#41; non-healthcare workers and 6 were patients who attended the facility&#46; Only four cases &#40;28&#46;5&#37;&#41; were immunized with 2 doses of MCV &#91;2 &#40;25&#37;&#41; men vs 2 &#40;33&#46;3&#37;&#41; women &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;156&#41; &#40;OR 0&#46;17 95&#37;CI 0&#46;02&#8211;1&#46;72&#41;&#93;&#46; 3 &#40;75&#37;&#41; of the vaccinated cases were healthcare workers&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Among the unvaccinated cases&#44; two siblings had not received the vaccine because of parental decision&#46; The eight remaining unvaccinated cases were born before 1981 when MCV was introduced to the systematic immunization schedule in Catalonia&#44; of these 3 &#40;37&#46;5&#37;&#41; were non-healthcare hospital workers &#40;cleaning&#47;maintenance&#41;</p><p id="par0085" class="elsevierStylePara elsevierViewall">No statistical difference was observed among hospital staff and community cases as to immunization status &#40;OR 2&#46;4 95&#37;CI&#58; 0&#46;17&#8211;32&#46;88&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;49&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Susceptible contacts of confirmed cases were isolated until the transmission period passed and if the contacts were healthcare workers&#44; in coordination with the hospital&#39;s Preventive Medicine and Occupational Health Service&#44; they were excluded from work&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The immune status of household and other contacts of cases was reviewed and according to protocol&#44; those not immunized were vaccinated&#46; Contact tracing of direct contacts of confirmed cases were carried out at least for 21 days after the last exposure to the case&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">HCW measles immunization verification</span><p id="par0100" class="elsevierStylePara elsevierViewall">According to the National Surveillance Network guidelines &#40;RENAVE&#41;&#44; active monitoring and monitoring of immune status among primary and hospital health workers was carried out from the hospital&#39;s Preventive Medicine and Occupational Health Department&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Registered serologic evidence of immunity or of receipt of MCV&#46; Hospital staff without evidence of measles immunity had blood samples drawn for serological testing and were offered MMR vaccination &#40;1&#8211;2 doses 28 days apart if needed to complete vaccination scheme&#41;&#46; Sixteen healthcare workers identified as contacts of confirmed cases and who tested negative or were not able to provide evidence of immunity were immunized and excluded from work&#46; A high level of protection was found for more than 95&#37; of the staff and all other unprotected or low measles IgG titles were vaccinated&#46; Workers who had fever or could not prove vaccination or having passed the disease were excluded from work 21 days after last exposure&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The occupational health services of hospital-linked external companies were also instructed to carry out active monitoring of their workers&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Exposure and contact investigations</span><p id="par0115" class="elsevierStylePara elsevierViewall">The search for the index case was carried out by reviewing the medical discharge records of all patients presenting with fever and rash&#44; who attended the emergency room service of the hospital between the 5th and 7th of March&#46; The index case was a patient that presented with a fever and rash of 24<span class="elsevierStyleHsp" style=""></span>h on March 7th &#40;date of rash onset March 6th&#41;&#44; and had been diagnosed as scarlet fever&#46; Another case had also had contact with the first at the ER when accompanying a relative on the same day&#44; 7th of March&#46; This contact was confirmed by PCR and genotype variant was identified as B3 MVs&#47;Dublin&#46;IRL&#47;8&#46;16-variant &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; At the time of identification of the suspected index case&#44; although recovered&#44; blood sample was collected and sent to the measles&#44; mumps and rubella reference laboratory of Catalonia at the Clinical Hospital of Barcelona&#46; Although nearly two months had passed&#44; serology resulted positive for IgM Measles specific antibodies confirming the case&#46; This index case&#39;s background revealed that&#44; from February 18th to 20th he had been visiting a relative admitted at the Hospital La Fe in Valencia where a measles outbreak was active&#46; The study of the genotype variant of the measles virus determined that the Tortosa hospital outbreak derived from a case infected in the La Fe hospital in Valencia and therefore derived from the same transmission chain as the outbreak reported in Valencia late in 2017 and which was active until July 2018&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">After two maximum incubation periods &#40;42 days&#41; from the date of rash onset of the last confirmed case on April 24th the outbreak was declared interrupted on June 6th 2018&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Despite high MCV coverage&#44; there are measles immunity gaps&#44; which can enhance transmission among young adults and specially HCWs&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;14</span></a> In highly communicable infectious diseases such as measles&#44; it is very important to carry out epidemiological research in the shortest possible time&#44; so as cases are reported&#44; the epidemiological investigation has to be initiated&#46; The first two cases reported were hospital employees&#44; but the following three cases did not have a clear link to the hospital&#46; However&#44; it was important to try to find out a missed case&#44; which would have initiated the local transmission chain&#46; Epidemiological evidence drove to the conclusion that the index case had to correspond to an individual attended at the emergency room &#40;ER&#41; and that had misdiagnosed&#46; Through the review of the cases and their circumstances it was inferred that the search had to be focused on patients who had only occasionally visited the hospital&#44; rather than hospital employees because of the difficulty to establish the time of the exposure of the latter&#46; A link was found for a case who had been at the ER accompanying a relative&#44; on March 7th&#44; the same day the suspected index case had been misdiagnosed&#44; in the ER&#44; as scarlet fever&#46; The index case was a 41-year-old man&#44; who had been visiting a relative admitted at the Hospital La Fe in Valencia from February 18th to 20th when a large measles outbreak was taking place at the facility&#46; There was spread to the community by this case linked to the index case&#44; with transmission to four other cases in nearby municipality&#46; This fact focuses on the importance of detecting suspected measles for any patient attended for fever and rash in order to establish isolation measures immediately and prevent nosocomial transmission&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Having been able to collect samples and determine MV genotype haplotype&#47;variant from 8 of the 14 cases from the outbreak allowed to prove that they belonged to the same chain of transmission as the outbreak occurring in the Hospital at Valencia&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12&#44;16&#44;17</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Still there was a case detected retrospectively in May&#44; by the laboratory reporting of an IgM positive serology in a nurse who presented fever and rash on March 23rd&#44; but unlike the index case&#44; this case did not cause any secondary transmission&#46; Although there was no registered immunization evidence&#44; she might have received an MMR dose at 11 years of age at school in 1990&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> This could explain why despite the delay in contact tracing due to delay in reporting as a measles case&#44; reduced transmissibility in vaccinated cases was responsible for the lack of transmission&#46; Laboratory results for three of the four 2 MCV dose vaccinated cases point at a lower viral charge with either urine and or pharyngeal specimens reporting negative to PCR testing&#46; This could also be an indication of lower transmissibility in immunized cases&#46; A recent study carried out in the United States by Gasta&#241;aduy et al&#46; found that unvaccinated patients with measles are approximately 3&#8211;4 times more Infectious compared with those cases vaccinated with one or two doses of MCV&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">This is an outbreak were the hospital facility has been the main source of infection of measles to mostly unvaccinated population while working&#44; consulting or visiting It is important to ensure that all HCWs have presumptive evidence of measles immunity&#44; either because of a registered immunization with two dose MCV or laboratory confirmed immunity by positive titer of IgG against measles&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> Current hiring policies for hospital facility employees should take into account all employees&#44; not only&#44; HCW as far as screening and immunization concerns&#46; In this outbreak&#44; this was carried out as a prevention and control measure in the context of the outbreak&#46; Although hospital employees did not sustain transmission&#44; it is highly important to underscore the need and cost-effectiveness of immunization with MCV to any health care facility employee&#44; whether they be health care workers&#44; students&#44; administration or maintenance employees&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Clinical presentation of cases might not be typical&#44; especially in young adults who have received one or two doses of MCV&#44; therefore clinicians should be alert and suspect measles in any patient consulting for rash and fever&#46; In this outbreak&#44; only one vaccinated case did not present rash&#44; yet 75&#37; of them did not present classic symptoms such as conjunctivitis&#44; cough or Koplik enanthema&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The linkage of the measles outbreak in Tortosa to the same chain of transmission of the Valencia outbreak of imported origin from Romania was identified being the isolated viruses a B3 MVs&#47;Dublin&#46;IRL&#47;8&#46;16-variant&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The outbreak allowed immune status revision of primary and hospital care network professionals in the area and updating vaccination according to serological data obtained&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">After suffering the infection&#44; immunity in people lasts a lifetime&#44; while immunity conferred by the vaccine can present a proportion equal to or less than 5&#37; that might have primary or secondary vaccine failure&#46; Waning of antibody protection after a few years has also been established as a possible cause of measles outbreaks in geographical areas where wild measles virus circulation is scarce and due to importations&#46; This would be one of the possible explanations for the contagion among the cases that were correctly vaccinated&#46; Atypical clinical presentation of symptoms was also found in some of these cases&#46; This fact has been observed in several studies and seems to become more frequent in adult cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#8211;28</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Except for the two unvaccinated siblings&#44; no other secondary cases of transmission occurred&#46; This&#44; along with the fact that the virus circulated intensely during the first few weeks&#44; indicates that there is a high level of immunity among the population of Tortosa and surrounding areas&#46; However&#44; susceptible population groups were found to be those unvaccinated because of their age&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The main limitation to this study is the small sample size which impairs statistical analysis of the data on clinical presentation&#44; complications and laboratory results&#44; yet it information deployed is relevant to implement more inclusive immunization policies for all personnel related to healthcare institutions as well as a higher sensitivity when suspecting measles at emergency room triage&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The outbreak was contained to few cases<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> due to high immunization coverage in the population&#44; prompt implementation of surveillance and control measures&#46; Nonetheless&#44; a higher immunization coverage of healthcare related personnel&#44; other non-health professionals who are related to these facilities with high risk of contagion&#44; has to be achieved and maintained in order to avoid nosocomial transmission and the economic impact of outbreaks on the institutions affected<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The unvaccinated population cohorts born before MMR vaccine was included in childhood immunization schedule also has to be consider as candidates for increased coverage&#46; The outbreak also raised awareness&#44; updated clinical knowledge on measles among the healthcare workers&#44; and triggered them to be alert as to possible new outbreaks&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Suspecting measles in cases presenting with exanthema and fever&#44; allows for immediate airborne isolation&#44; and retrieving measles immunity records for healthcare facility employees and contacts&#46; Such measures are of utmost importance in preventing health care-associated transmission and in minimizing hospital outbreak spillover to the community&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#44;30</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical issues</span><p id="par0185" class="elsevierStylePara elsevierViewall">Analysis of data and samples were performed under the epidemiologic surveillance of vaccine preventable diseases established for Public Health Surveillance purposes&#44; there is no need for individual signed consent&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Financial disclosure</span><p id="par0190" class="elsevierStylePara elsevierViewall">No funding received&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">N&#46; Torner is member of the editorial team of the journal&#46; Other authors declare there is no conflict of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:13 [
        0 => array:3 [
          "identificador" => "xres1519856"
          "titulo" => "Abstract"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "abst0005"
              "titulo" => "Introduction"
            ]
            1 => array:2 [
              "identificador" => "abst0010"
              "titulo" => "Methods"
            ]
            2 => array:2 [
              "identificador" => "abst0015"
              "titulo" => "Results"
            ]
            3 => array:2 [
              "identificador" => "abst0020"
              "titulo" => "Conclusion"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1378169"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres1519855"
          "titulo" => "Resumen"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "abst0025"
              "titulo" => "Introducci&#243;n"
            ]
            1 => array:2 [
              "identificador" => "abst0030"
              "titulo" => "M&#233;todos"
            ]
            2 => array:2 [
              "identificador" => "abst0035"
              "titulo" => "Resultados"
            ]
            3 => array:2 [
              "identificador" => "abst0040"
              "titulo" => "Conclusi&#243;n"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1378168"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Methods"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Case investigation and outbreak response"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0020"
          "titulo" => "Results"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Outbreak descriptive epidemiology"
            ]
            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "HCW measles immunization verification"
            ]
            2 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Exposure and contact investigations"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Ethical issues"
        ]
        9 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Financial disclosure"
        ]
        10 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflict of interest"
        ]
        11 => array:2 [
          "identificador" => "xack534017"
          "titulo" => "Acknowledgements"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-03-30"
    "fechaAceptado" => "2020-08-06"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1378169"
          "palabras" => array:4 [
            0 => "Measles"
            1 => "Outbreak"
            2 => "Nosocomial transmission"
            3 => "Immunization"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1378168"
          "palabras" => array:4 [
            0 => "Sarampi&#243;n"
            1 => "Brote epid&#233;mico"
            2 => "Transmisi&#243;n nosocomial"
            3 => "Inmunizaci&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Measles has a high transmission rate among susceptible populations&#46; Healthcare facilities can play an important role in measles transmission&#46; The aim of this study is to describe a measles outbreak in a highly immunized community and the implication of healthcare workers in the transmission of the disease&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descriptive study of measles outbreak linked to hospital setting with sociodemographic&#44; clinical&#44; virological and immunization variables studied&#46; Cases were confirmed by RT-PCR in clinical specimens and genotyped by nucleotide sequencing&#46; Association was assessed by chi<span class="elsevierStyleSup">2</span>&#44; Fisher&#39;s exact and <span class="elsevierStyleItalic">z</span> test&#46; Statistical significance at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">47 suspected measles cases were reported from March to June 2018 at Terres de l&#8217;Ebre&#44; Catalonia&#46; Fourteen cases were confirmed&#44; 8 cases &#40;57&#37;&#41; were men&#59; median age of cases 33y &#40;range 16&#8211;46 y&#41;&#46; Hospital associated transmission was confirmed in 13 &#40;93&#37;&#41; cases&#44; 8 &#40;61&#46;5&#37;&#41; were hospital staff&#46; Five &#40;38&#46;5&#37;&#41; were healthcare workers &#40;HCW&#41;&#44; three &#40;23&#37;&#41; non-healthcare workers &#40;non-HCW&#41; and 6 &#40;46&#37;&#41; were patients attended at the hospital&#46; Four cases &#40;28&#46;5&#37;&#41; were immunized with 2 doses of measles virus containing vaccine &#40;MCV&#41;&#59; 3 &#40;75&#37;&#41; were HCW&#46; No statistical difference observed among hospital staff and community cases as to immunization &#40;OR 2&#46;4 95&#37;CI&#58; 0&#46;17&#8211;32&#46;88&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;49&#41;&#46; Genotype B3 MVs&#47;Dublin&#46;IRL&#47;8&#46;16-variant was obtained from confirmed cases&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Suspecting measles diagnosis&#44; allows for immediate airborne isolation&#44; and retrieving measles immunity records for healthcare facility employees and contacts&#46; Vaccination of HCW and the adoption of good infection control will minimize nosocomial transmission and spreading of the virus to the community&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El sarampi&#243;n tiene una elevada tasa de transmisi&#243;n entre poblaciones susceptibles&#46; Los centros sanitarios pueden desempe&#241;ar un papel importante en la transmisi&#243;n del sarampi&#243;n&#46; El objetivo de este estudio es describir un brote de sarampi&#243;n en una poblaci&#243;n con elevada cobertura de inmunizaci&#243;n y la implicaci&#243;n de los trabajadores sanitarios en la transmisi&#243;n de la enfermedad&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo de un brote de sarampi&#243;n vinculado al entorno hospitalario&#46; Se estudiaron variables sociodemogr&#225;ficas&#44; cl&#237;nicas&#44; virol&#243;gicas y de estado vacunal de los casos&#46; Se confirmaron los casos por RT-PCR en muestras cl&#237;nicas y posterior genotipado por secuenciaci&#243;n nucleot&#237;dica&#46; An&#225;lisis estad&#237;stico mediante &#967;<span class="elsevierStyleSup">2</span>&#44; prueba exacta de Fisher y test z&#59; nivel de significaci&#243;n estad&#237;stica p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De marzo a junio de 2018 se notificaron un total de 47 casos sospechosos de sarampi&#243;n en Terres de l&#8217;Ebre&#44; Catalu&#241;a &#40;Espa&#241;a&#41;&#46; Hubo 14 casos&#44; y 8 &#40;57&#37;&#41; eran hombres&#59; mediana de edad&#44; 33<span class="elsevierStyleHsp" style=""></span>a&#241;os &#40;rango 16-46<span class="elsevierStyleHsp" style=""></span>a&#241;os&#41;&#46; Se confirm&#243; transmisi&#243;n hospitalaria en 13 &#40;93&#37;&#41; de los casos&#59; 8 &#40;61&#44;5&#37;&#41; eran personal hospitalario&#46; Cinco &#40;38&#44;5&#37;&#41; eran personal sanitario &#40;PS&#41;&#44; 3 &#40;23&#37;&#41; Pno-S y 6 &#40;46&#37;&#41; eran pacientes del hospital&#46; Cuatro &#40;28&#44;5&#37;&#41; estaban vacunados con 2 dosis de vacuna antisarampi&#243;n &#40;TV&#41;&#44; 3 de los cuales &#40;75&#37;&#41; eran PS&#46; No se observ&#243; diferencia significativa entre personal hospitalario y casos comunitarios sobre estado vacunal &#40;OR&#58; 2&#44;4&#59; IC<span class="elsevierStyleHsp" style=""></span>95&#37;&#58; 0&#44;17-32&#44;88&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;49&#41;&#46; Se identific&#243; genotipo B3 MVs&#47;Dublin&#46;IRL&#47;8&#46;16-variant en los casos confirmados por PCR&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La sospecha de sarampi&#243;n como diagn&#243;stico permite el aislamiento inmediato de los casos y la revisi&#243;n del estado vacunal frente al sarampi&#243;n de personal y contactos de los centros sanitarios&#46; La vacunaci&#243;n del personal sanitario y el seguimiento de buenas pr&#225;cticas de control y prevenci&#243;n de la infecci&#243;n permiten disminuir el riesgo de transmisi&#243;n nosocomial&#44; as&#237; como la diseminaci&#243;n del virus y su repercusi&#243;n en la comunidad&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1584
            "Ancho" => 2917
            "Tamanyo" => 298217
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of reported cases &#40;confirmed and discarded cases&#41; according to day of rash onset &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>47&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1244
            "Ancho" => 2167
            "Tamanyo" => 110551
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Distribution of confirmed cases according to age group and gender&#46; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; CNE informe annual MMR 2018&#46;"
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 2537
            "Ancho" => 2167
            "Tamanyo" => 483456
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Phylogenetic tree of N450 sequences of strain haplotype&#47;variants circulating in Spain in 2018&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "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"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total number of cases &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Unvaccinated cases &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vaccinated cases &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Symptoms</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rash&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">13 &#40;92&#46;9&#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">10 &#40;100&#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">3 &#40;75&#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">0&#46;622&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fever&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;100&#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">10 &#40;100&#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">4 &#40;100&#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">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Coryza&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;28&#46;6&#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;20&#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;50&#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">0&#46;640&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " 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
                  \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">6 &#40;42&#46;9&#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">5 &#40;50&#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">1 &#40;25&#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">0&#46;798&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Conjunctivitis&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;21&#46;4&#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;20&#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">1 &#40;25&#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">0&#46;607&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Koplik enanthema&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;21&#46;4&#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;20&#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">1 &#40;25&#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">0&#46;607&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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Complications</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otitis media&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 &#40;0&#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">0 &#40;0&#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">0 &#40;0&#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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diarreas&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;7&#46;1&#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">1 &#40;10&#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">0 &#40;0&#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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nausea&#47;vomitus&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;21&#46;4&#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;20&#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">1 &#40;25&#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">0&#46;607&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Faringitis&#47;tonsilitis&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;14&#46;2&#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">1 &#40;10&#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">1 &#40;25&#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">0&#46;904&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Joint pain&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;7&#46;1&#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">1 &#40;10&#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">0 &#40;0&#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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Headache&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;7&#46;1&#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">1 &#40;10&#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">0 &#40;0&#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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Encefalitis&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 &#40;0&#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">0 &#40;0&#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">0 &#40;0&#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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pneumonia&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 &#40;0&#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">0 &#40;0&#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">0 &#40;0&#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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2610057.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation and complications of cases according to immunization status&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "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"><th 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" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MMR timingFirst&#47;second dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Urine PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pharyngeal swabPCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Serum IgM antibody detection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&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">1999&#47;2003&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">Positive&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">Positive&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">&#8211;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&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">1993&#47;1999&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">Positive&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">Negative&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">Positive&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&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">2000&#47;2002&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">Negative&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">Negative&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">Positive&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&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">1985&#47;1989&#47;1995<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Negative&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">Positive&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">Low titer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2610056.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Hospital staff&#44; immunized at staff enrollment&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Distribution of MMR measles immunization&#44; first and second dose&#44; and laboratory results of cases immunized with 2 dose MCV&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:30 [
            0 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measles"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "W&#46;J&#46; Moss"
                            1 => "D&#46;E&#46; Griffin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(10)62352-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2012"
                        "volumen" => "379"
                        "paginaInicial" => "153"
                        "paginaFinal" => "164"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21855993"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Generalitat de Catalunya&#46; Departament de Salut&#46; L&#8217;eliminaci&#243; del xarampi&#243; a Catalunya per a l&#8217;any 2000&#46; Bases cient&#237;fiques i programa&#46; Barcelona&#59; 1999&#46; &#40;Quaderns de Salut P&#250;blica&#41;&#46; Report No&#46;&#58; 12&#46; Available from&#58; <a target="_blank" href="http://canalsalut.gencat.cat/web/.content/_A-Z/X/xarampio/arxius/eliminacioxarampio.pdf">http&#58;&#47;&#47;canalsalut&#46;gencat&#46;cat&#47;web&#47;&#46;content&#47;&#95;A-Z&#47;X&#47;xarampio&#47;arxius&#47;eliminacioxarampio&#46;pdf</a>&#46;"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Estado inmunitario de la poblaci&#243;n espa&#241;ola frente a las enfermedades inmunoprevenibles mediante vacunaciones sistem&#225;ticas"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Salleras"
                            1 => "N&#46; Soldevila"
                            2 => "A&#46; Dom&#237;nguez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Vacunas"
                        "fecha" => "2015"
                        "volumen" => "16"
                        "paginaInicial" => "18"
                        "paginaFinal" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Centro Nacional de Epidemiolog&#237;a&#46; Protocolos de la Red Nacional de Vigilancia Epidemiol&#243;gica&#46; Madrid&#59; 2015&#46; Available from&#58; <a target="_blank" href="https://publicaciones.isciii.es/">https&#58;&#47;&#47;publicaciones&#46;isciii&#46;es&#47;</a>&#46;"
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Ministerio de Sanidad consumo y bienestar social&#59; Direccii&#243;n general de Salud P&#250;blica Coberturas vacunales en Espa&#241;a&#46; Madrid&#46; 2019&#46; Available from&#58; <a target="_blank" href="https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/CoberturasVacunacion/Todas_las_tablas.pdf">https&#58;&#47;&#47;www&#46;mscbs&#46;gob&#46;es&#47;profesionales&#47;saludPublica&#47;prevPromocion&#47;vacunaciones&#47;docs&#47;CoberturasVacunacion&#47;Todas&#95;las&#95;tablas&#46;pdf&#35;page&#61;12020</a> &#91;cited June 30&#93;&#46;"
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vaccines for measles&#44; mumps and rubella in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "V&#46; Demicheli"
                            1 => "A&#46; Rivetti"
                            2 => "M&#46;G&#46; Debalini"
                            3 => "C&#46; Di Pietrantonj"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/14651858.CD004407.pub3"
                      "Revista" => array:2 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2012"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measles and measles vaccination"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;C&#46; Bester"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jamapediatrics.2016.1787"
                      "Revista" => array:5 [
                        "tituloSerie" => "JAMA Pediatr"
                        "fecha" => "2016"
                        "volumen" => "170"
                        "paginaInicial" => "1209"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27695849"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measles vaccine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46;E&#46; Griffin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1089/vim.2017.0143"
                      "Revista" => array:6 [
                        "tituloSerie" => "Viral Immunol"
                        "fecha" => "2018"
                        "volumen" => "31"
                        "paginaInicial" => "86"
                        "paginaFinal" => "95"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29256824"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Genetic characterization of measles vaccine strains"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "B&#46; Bankamp"
                            1 => "M&#46; Takeda"
                            2 => "Y&#46; Zhang"
                            3 => "W&#46; Xu"
                            4 => "P&#46;A&#46; Rota"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/infdis/jir097"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "204"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "S533"
                        "paginaFinal" => "S548"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21666210"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Children and adolescents unvaccinated against measles&#58; geographic clustering&#44; parents&#8217; beliefs&#44; and missed opportunities"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "P&#46;J&#46; Smith"
                            1 => "E&#46;K&#46; Marcuse"
                            2 => "J&#46;F&#46; Seward"
                            3 => "Z&#46; Zhao"
                            4 => "W&#46;A&#46; Orenstein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/003335491513000512"
                      "Revista" => array:6 [
                        "tituloSerie" => "Public Health Rep"
                        "fecha" => "2015"
                        "volumen" => "130"
                        "paginaInicial" => "485"
                        "paginaFinal" => "504"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26327727"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measles virus genotype circulation in Spain after implementation of the national measles elimination plan 2001&#8211;2003"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;M&#46; Mosquera"
                            1 => "F&#46; Ory"
                            2 => "de"
                            3 => "J&#46;E&#46; Echevarr&#237;a"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/jmv.20248"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Med Virol"
                        "fecha" => "2005"
                        "volumen" => "75"
                        "paginaInicial" => "137"
                        "paginaFinal" => "146"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15543577"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Instituto de Salud Carlos III&#46; CIBERESP y Ministerio de Sanidad Consumo y Bienestar Social&#46; Plan de Eliminaci&#243;n del Sarampi&#243;n y Rubeola&#44; Espa&#241;a 2018&#46; 2019&#46;"
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ongoing outbreak with well over 4&#44;000 measles cases in Italy from January to end August 2017 &#8211; what is making elimination so difficult&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Filia"
                            1 => "A&#46; Bella"
                            2 => "M&#46; Del Manso"
                            3 => "M&#46; Baggieri"
                            4 => "F&#46; Magurano"
                            5 => "M&#46;C&#46; Rota"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2807/1560-7917.ES.2017.22.37.30614"
                      "Revista" => array:5 [
                        "tituloSerie" => "Eurosurveillance"
                        "fecha" => "2017"
                        "volumen" => "22"
                        "paginaInicial" => "30614"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28933342"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Workplace vaccination against measles in a teaching hospital of Rome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "L&#46; Coppeta"
                            1 => "A&#46; Pietroiusti"
                            2 => "L&#46; Morucci"
                            3 => "A&#46; Neri"
                            4 => "M&#46; Ferraro"
                            5 => "A&#46; Magrini"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2018.11.022"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2019"
                        "volumen" => "101"
                        "paginaInicial" => "364"
                        "paginaFinal" => "365"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30529439"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "World Health Organization W&#46; Guide for clinical case management and infection prevention and control during a measles outbreak&#46; Geneva&#58; WHO&#59; 2020&#46; 34 p&#46; Available from&#58; <a target="_blank" href="https://apps.who.int/iris/bitstream/handle/10665/331599/9789240002869-eng.pdf?sequence=1%26isAllowed=y">https&#58;&#47;&#47;apps&#46;who&#46;int&#47;iris&#47;bitstream&#47;handle&#47;10665&#47;331599&#47;9789240002869-eng&#46;pdf&#63;sequence&#61;1&#38;isAllowed&#61;y</a>&#46;"
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Tran T&#44; Kostecki R&#44; Catton M&#44; Druce J&#46; Utility of a stressed single nucleotide polymorphism &#40;SNP&#41; real-time PCR assay for rapid identification of measles vaccine strains in patient samples&#46; Tang Y-W&#44; editor&#46; J Clin Microbiol&#46; 2018&#59;56&#46; Available from&#58; <a target="_blank" href="http://jcm.asm.org/lookup/doi/10.1128/JCM.00360-18">http&#58;&#47;&#47;jcm&#46;asm&#46;org&#47;lookup&#47;doi&#47;10&#46;1128&#47;JCM&#46;00360-18</a>&#46;"
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The importance of serological and molecular analyses for the diagnosis of measles cases and for meeting elimination targets in Turkey from 2007 to 2015"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Y&#46; Cosgun"
                            1 => "D&#46; Guldemir"
                            2 => "A&#46; Coskun"
                            3 => "S&#46; Yolbakan"
                            4 => "A&#46;T&#46; Kalaycioglu"
                            5 => "G&#46; Korukluoglu"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1017/S0950268818000432"
                      "Revista" => array:6 [
                        "tituloSerie" => "Epidemiol Infect"
                        "fecha" => "2018"
                        "volumen" => "146"
                        "paginaInicial" => "735"
                        "paginaFinal" => "740"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29534775"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Factors associated with measles transmission in the United States during the postelimination era"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;A&#46; Gasta&#241;aduy"
                            1 => "S&#46; Funk"
                            2 => "B&#46;A&#46; Lopman"
                            3 => "P&#46;A&#46; Rota"
                            4 => "M&#46; Gambhir"
                            5 => "B&#46; Grenfell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jamapediatrics.2019.4357"
                      "Revista" => array:5 [
                        "tituloSerie" => "JAMA Pediatr"
                        "fecha" => "2020"
                        "volumen" => "174"
                        "paginaInicial" => "56"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31738391"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "World Health Organization W&#46; Guide for clinical case management and infection prevention and control during a measles outbreak Geneve&#59; 2020 34 &#40;Institutional Repository for Information Series IRIS&#41;&#46; Available from&#58; <a target="_blank" href="https://apps.who.int/iris/handle/10665/331599">https&#58;&#47;&#47;apps&#46;who&#46;int&#47;iris&#47;handle&#47;10665&#47;331599</a>&#46;"
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cost-effectiveness of workplace vaccination against measles"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "L&#46; Coppeta"
                            1 => "L&#46; Morucci"
                            2 => "A&#46; Pietroiusti"
                            3 => "A&#46; Magrini"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1080/21645515.2019.1616505"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hum Vaccin Immunother"
                        "fecha" => "2019"
                        "volumen" => "15"
                        "paginaInicial" => "2847"
                        "paginaFinal" => "2850"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31339463"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measles&#44; rubella&#44; mumps&#44; and varicella seroprevalence among health care workers in Turkey&#58; is prevaccination screening cost-effective&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Celikbas"
                            1 => "O&#46; Ergonul"
                            2 => "S&#46; Aksaray"
                            3 => "N&#46; Tuygun"
                            4 => "H&#46; Esener"
                            5 => "G&#46; Tan&#305;r"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ajic.2006.04.213"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Infect Control"
                        "fecha" => "2006"
                        "volumen" => "34"
                        "paginaInicial" => "583"
                        "paginaFinal" => "587"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17097453"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Amoroso A&#44; editor&#46; Fever with rash in a healthy adult&#46; Clin Infect Dis&#46; 2016&#59;62&#58;1021&#46; Available from&#58; <a target="_blank" href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciw062">https&#58;&#47;&#47;academic&#46;oup&#46;com&#47;cid&#47;article-lookup&#47;doi&#47;10&#46;1093&#47;cid&#47;ciw062</a>&#46;"
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Modified measles with an atypical presentation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46;M&#46; Uren"
                            1 => "B&#46;R&#46; Vasant"
                            2 => "D&#46; Judd"
                            3 => "D&#46;F&#46; Looke"
                            4 => "A&#46;J&#46; Henderson"
                            5 => "K&#46;A&#46; Jarvinen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Commun Dis Intell"
                        "fecha" => "2019"
                        "volumen" => "17"
                        "paginaInicial" => "43"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recognizing measles mumps&#44; and rubella in the emergency department"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46; Gadler"
                            1 => "N&#46; Martinez"
                            2 => "J&#46; Ogg-Gress"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/TME.0000000000000190"
                      "Revista" => array:6 [
                        "tituloSerie" => "Adv Emerg Nurs J"
                        "fecha" => "2018"
                        "volumen" => "40"
                        "paginaInicial" => "110"
                        "paginaFinal" => "118"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29715253"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0275"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fever and rash&#58; revisiting measles"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;R&#46; Barbosa"
                            1 => "A&#46;S&#46; Martins"
                            2 => "J&#46; Ruivo"
                            3 => "L&#46; Carvalho"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.20344/amp.9776"
                      "Revista" => array:5 [
                        "tituloSerie" => "Acta Med Port"
                        "fecha" => "2018"
                        "volumen" => "31"
                        "paginaInicial" => "341"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30020880"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Viral exanthems&#58; an update on laboratory testing of the adult patient"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;M&#46; Korman"
                            1 => "A&#46; Alikhan"
                            2 => "B&#46;H&#46; Kaffenberger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2016.08.034"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2017"
                        "volumen" => "76"
                        "paginaInicial" => "538"
                        "paginaFinal" => "550"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28413059"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0285"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Atypical measles syndrome in adults&#58; still around"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "C&#46; Melenotte"
                            1 => "N&#46; Cassir"
                            2 => "L&#46; Tessonnier"
                            3 => "P&#46; Brouqui"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "BMJ Case Rep"
                        "fecha" => "2015"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A forty-four year-old immunized woman with maculopapular and petechial rash diagnosed as measles&#58; an extremely rare presentation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Sali"
                            1 => "A&#46; Yazdani"
                            2 => "Z&#46; Doosti"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Int J Infect"
                        "fecha" => "2018"
                        "volumen" => "5"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0295"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measles among healthcare workers in Italy&#58; is it time to act&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "V&#46; Baccolini"
                            1 => "A&#46; Sindoni"
                            2 => "G&#46; Adamo"
                            3 => "A&#46; Rosso"
                            4 => "A&#46; Massimi"
                            5 => "A&#46; Bella"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Hum Vaccin Immunother"
                        "fecha" => "2020"
                        "volumen" => "25"
                        "paginaInicial" => "1"
                        "paginaFinal" => "10"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Health care-associated measles outbreak in the United States after an importation&#58; challenges and economic impact"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;Y&#46; Chen"
                            1 => "S&#46; Anderson"
                            2 => "P&#46;K&#46; Kutty"
                            3 => "F&#46; Lugo"
                            4 => "M&#46; McDonald"
                            5 => "P&#46;A&#46; Rota"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/infdis/jir115"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "203"
                        "paginaInicial" => "1517"
                        "paginaFinal" => "1525"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21531693"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S1474442218302394"
                          "estado" => "S300"
                          "issn" => "14744422"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:4 [
        "identificador" => "xack534017"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0200" class="elsevierStylePara elsevierViewall">We thank the collaboration of Josefa Masa Calles and Noemi Lopez Perea &#40;Enfermedades Inmunoprevenibles&#46; CIBERESP&#44; Centro Nacional de Epidemiolog&#237;a Instituto de Salud Carlos III&#44; Madrid&#41; and the reporting physicians of the hospital and primary care centers of the Terres de l&#8217;Ebre Health Region&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15769887/0000002200000001/v2_202106031157/S157698872030042X/v2_202106031157/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "10130"
    "tipo" => "SECCION"
    "es" => array:2 [
      "titulo" => "Originales"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "es"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/15769887/0000002200000001/v2_202106031157/S157698872030042X/v2_202106031157/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157698872030042X?idApp=UINPBA00004N"
]

Article information

ISSN: 15769887
Original language: English

DOI:10.1016/j.vacun.2020.08.002

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	2	2	4
2024 October	9	9	18
2024 September	5	5	10
2024 August	7	5	12
2024 July	10	9	19
2024 June	9	9	18
2024 May	11	7	18
2024 April	7	6	13
2024 March	9	5	14
2024 February	8	3	11
2024 January	6	0	6
2023 December	9	0	9
2023 November	9	0	9
2023 October	23	0	23
2023 September	9	0	9
2023 August	12	0	12
2023 July	13	2	15
2023 June	3	2	5
2022 November	3	3	6
2022 October	5	5	10
2022 September	4	5	9
2021 June	7	2	9
2021 May	1	0	1

Show all

Indexed in:

Follow us:

Subscribe:

Statistics

Indexed in:

Follow us:

Subscribe:

Statistics

Subscribe to our newsletter