Executive summary of the update and reflection document on influenza vaccination in Spain

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"apellidos" => "Lopez Trigo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Asociación Española de Vacunología, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Asociación Española de Pediatría, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sociedad Española de Médicos de Atención Primaria, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Sociedad Española de Médicos Generales y de Familia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Sociedad Española de Medicina Preventiva, Salud Pública e Higiene, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Sociedad Española de Geriatría y Gerontología, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resumen ejecutivo del documento de actualización y reflexión sobre vacunación antigripal en España" ] ] "textoCompleto" => "PresentationInfluenza is the most common immune preventable disease in developed countries; it can affect people of all ages and cause epidemics.<a class="elsevierStyleCrossRef" href="#bib0625">1</a> It affects from 5% to 15% of the population annually, occasionally exceeding 50% in sectors living together in close-knit environments such as boarding schools or care homes for the elderly.<a class="elsevierStyleCrossRefs" href="#bib0625">1,2</a> Although the symptoms are usually mild and the disease resolves in a few days, it can have complications that require hospitalisation and, in some cases, cause death.<a class="elsevierStyleCrossRef" href="#bib0630">2</a>It is important therefore that health professionals and the general population are aware of the impact of this disease and the benefits of its prevention, to reduce the major health and social burden of seasonal influenza on the population, especially the most vulnerable groups. The Influenza Study Group and the signatory scientific societies and professional organisations have drawn up a document on influenza vaccination, detailing the scientific evidence behind its benefits, particularly for certain sectors of the population.<a class="elsevierStyleCrossRef" href="#bib0635">3</a> The aim is to contribute to meeting the recommendations of the World Health Organisation (WHO) and achieve influenza vaccination coverage of at least 75% among people over the age of 65 and those at high risk,<a class="elsevierStyleCrossRef" href="#bib0640">4</a> as well as healthcare professionals. This executive summary brings together the essential aspects of this document.Introduction to influenzaThe influenza virus typesThe influenza virus is classified into 3 types: A, B and C (although there is evidence of a fourth type, D<a class="elsevierStyleCrossRef" href="#bib0645">5</a>). Types A and B are responsible for most cases of infection in human beings and cause seasonal epidemia.<a class="elsevierStyleCrossRef" href="#bib0650">6</a> Two subtypes of virus A (H1N1) and A(H3N2)<a class="elsevierStyleCrossRef" href="#bib0655">7</a> are currently circulating in the population, and 2 type B virus lineages.The A virus has been responsible for all known pandemics.<a class="elsevierStyleCrossRefs" href="#bib0625">1,8</a> It has important rates of spontaneous mutation, which causes changes in its genome,<a class="elsevierStyleCrossRef" href="#bib0665">9</a> which in turn results in the appearance of new viral strains. It is the appearance of these new viral subtypes that can cause pandemic outbreaks.<a class="elsevierStyleCrossRefs" href="#bib0650">6,10–12</a>Two lineages of the B influenza virus (B/Yamagata and B/Victoria) have been co-circulating since the mid-nineteen eighties that are antigenically and phylogenetically distinct.<a class="elsevierStyleCrossRefs" href="#bib0685">13,14</a> Infants and young adults are most commonly affected by influenza B disease.<a class="elsevierStyleCrossRef" href="#bib0695">15</a> Although the influenza A virus (H3N2) has been related to higher rates of hospitalisation and death, major morbidity and mortality are associated with the type B virus which, in general, exceed those of subtype A(H1N1).<a class="elsevierStyleCrossRefs" href="#bib0685">13,16,17</a>TransmissionInfluenza is mainly transmitted by close contact (1–2m) through droplets expelled by coughing or sneezing. It can also be spread by contact with surfaces, objects or hands that have been contaminated by respiratory secretions. The transmissibility period of an infected person is from 24h to 48h before symptoms appear until 5 days afterwards. Children, the elderly and immunosuppressed people can be contagious for longer (up to 7–10 days afterwards).<a class="elsevierStyleCrossRef" href="#bib0625">1</a>Clinical features and symptomsInitial clinical symptoms are usually sudden in onset with fever and chills, accompanied by headache, nasal congestion, sore throat, general malaise, muscle pain, loss of appetite and dry cough.<a class="elsevierStyleCrossRefs" href="#bib0630">2,6</a> The current definition for influenza is that proposed by the European Union: “sudden onset of symptoms and at least one of the following four systemic symptoms: fever or feverishness, malaise, headache, myalgia; and at least one of the following three respiratory symptoms: cough, sore throat, shortness of breath, as well as the absence of other diagnostic suspicion”.<a class="elsevierStyleCrossRef" href="#bib0710">18</a> The secondary diseases most commonly associated with influenza are pneumonia, bronchitis, sinusitis and otitis, and exacerbation of other pre-existing chronic diseases. Severe infections can cause heart problems, meningitis, encephalitis or meningoencephalitis.<a class="elsevierStyleCrossRef" href="#bib0630">2</a>Economic and social impact of influenzaInfluenza presents in the form of seasonal epidemic outbreaks. These occur in the winter months in Spain (generally from November to March) and most cases appear over a 6–8 week time frame. However, the start of this period and the extension and severity of each epidemic vary from one year to another.<a class="elsevierStyleCrossRef" href="#bib0625">1</a>MortalityA recent modelling study, with data from 33 countries from 1999 until 2015, indicated that influenza-related respiratory mortality might account for 291,243 and 645,832 annual deaths (4.0–8.8 deaths per 100,000 inhabitants)<a class="elsevierStyleCrossRef" href="#bib0715">19</a>; these are the figures used by the WHO since 2017.<a class="elsevierStyleCrossRef" href="#bib0720">20</a> The disease particularly affects the paediatric population (2.1 and 23.8 annual deaths per 100,000),<a class="elsevierStyleCrossRef" href="#bib0715">19</a> although the most severe cases are principally people over the age of 65 (2.9–44.0 and 17.9–223 deaths per 100,000 inhabitants among those aged from 65 to 75 and those aged over 75, respectively)<a class="elsevierStyleCrossRef" href="#bib0715">19</a> and people with chronic illnesses.<a class="elsevierStyleCrossRefs" href="#bib0625">1,2,21–23</a> In Spain, in the last 5 seasons, most of the influenza outbreaks took place in geriatric care homes, where up to 80% of cases occurred in the season 2016–2017, healthcare centres and other similar institutions.<a class="elsevierStyleCrossRef" href="#bib0740">24</a> Three thousand one hundred and one (11.4% of deaths) confirmed, hospitalised cases of severe influenza were reported to the Spanish Influenza Surveillance System in the season 2015–2016. It is worth highlighting that of the people who were hospitalised or who died due to the disease in the season 2016–2017, only 52% who belonged to groups for whom influenza vaccination is recommended had been vaccinated.<a class="elsevierStyleCrossRef" href="#bib0740">24</a>Economic impactThere is a considerable increase in care demand during the influenza season. The costs associated with an influenza season in a country like Spain can exceed 1000 million Euros.<a class="elsevierStyleCrossRefs" href="#bib0745">25,26</a> A quarter of this amount is for direct costs; the remainder covers labour costs. On average, every case of influenza results in 5–6 days of limited activity, 3–4 days of restricted activity/bed rest, and around 3 days of absence from work.<a class="elsevierStyleCrossRef" href="#bib0755">27</a>Influenza vaccination and its benefitsTypes of influenza vaccinesThe influenza vaccines are classified into 2 large groups: (i) inactivated flu vaccines and (ii) live attenuated vaccines. Some can be used from the age of 6 months, but others are indicated for specific age groups (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0655">7,28–31</a> The current vaccination campaigns in Spain mainly use the trivalent vaccines (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Tetravalent split-virus vaccines have been developed in recent years, containing 2 B virus strains, one of each lineage, in order to avoid mismatch between the B vaccine strain and the B strain circulating in each season. The tetravalent vaccines increase the level of protection without modifying the safety or immunogenicity profile, compared to the trivalent vaccines. These advantages might make these the gold standard in influenza prevention in the near future.<a class="elsevierStyleCrossRefs" href="#bib0780">32–34</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>EffectivenessInfluenza vaccination is the most effective way of preventing the disease and its complications.<a class="elsevierStyleCrossRefs" href="#bib0780">32,35–37</a> Due to the antigenic drift, the influenza vaccine is reformulated every year to adjust to the type of virus that is expected to be circulating that season, therefore there is some uncertainty as to effectiveness every year.<a class="elsevierStyleCrossRef" href="#bib0655">7</a> The vaccine's effectiveness varies for different reasons; some inherent to its design, such as the match or mismatch between the strains in the vaccine and that year's circulating strains; the type of vaccine – attenuated or inactivated – or the administration route; but the features of the virus and of the individual vaccinated also have an influence.<a class="elsevierStyleCrossRefs" href="#bib0720">20,38</a> In general, and without going into this variability, overall effectiveness is around 65%.<a class="elsevierStyleCrossRefs" href="#bib0655">7,39</a> In studies from the nineteen eighties, 30–74% protection has been documented for healthy young people – adults, and 42–72% for people over the age of 59, depending on the season.<a class="elsevierStyleCrossRef" href="#bib0820">40</a> Likewise, it is estimated that the number of hospitalisations due to pneumonia of people over the age of 65 is reduced by almost 80%, and the mortality of people over the age of 75 with chronic illnesses is reduced by approximately 22%.<a class="elsevierStyleCrossRefs" href="#bib0825">41–43</a> Various authors have indicated that the seasonal tetravalent vaccine would increase protection reducing the problems associated with mismatch.<a class="elsevierStyleCrossRefs" href="#bib0655">7,13,15,44–47</a> Over the past 10 seasons there has been mismatch between the circulating B strain and the vaccine content on 5 occasions (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>SafetyThe inactivated influenza vaccines have excellent profiles of safety and adverse events; if they do occur, they are usually mild local or systemic. More than 300 million doses are distributed every year and major side effects are extremely rare with any type of influenza virus.<a class="elsevierStyleCrossRef" href="#bib0805">37</a>Vaccines available in SpainTrivalent and tetravalent vaccines are currently available in Spain (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). They all have the same influenza virus strains in each season, those recommended by the WHO and the European Union each year<a class="elsevierStyleCrossRefs" href="#bib0685">13,48,49</a>: 2 A strains and 2 B strains, one from each lineage, for the tetravalents, and the B strain specifically selected for the trivalents.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Contraindications and precautionsThe features of the individual that increase their risk of an adverse reaction and the precautions to be taken to minimise this risk should be known. Before vaccination the patient should be checked for any contraindications or whether a precaution should be taken,<a class="elsevierStyleCrossRefs" href="#bib0795">35,50,51</a> checking the updated version of the vaccine's datasheet (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). International committees of experts consider that an egg allergy is no longer a contraindication for the influenza vaccine, although it is included on the influenza vaccine datasheets in Spain.<a class="elsevierStyleCrossRefs" href="#bib0795">35,52</a><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Risk groupsAlthough the general population is vulnerable to infection by the influenza virus, there are groups that are more likely to transmit the virus to others, to develop complications or even die as a consequence of the disease.<a class="elsevierStyleCrossRef" href="#bib0885">53</a> The health authorities recommend vaccination against influenza particularly for those at greater risk of presenting complications. This group includes those aged over 65, the chronically sick, immunosuppressed people and pregnant women.<a class="elsevierStyleCrossRefs" href="#bib0885">53–55</a> In addition, vaccination is recommended for people who might transmit the disease to others at high risk of complications and those who, due to their occupation, provide essential community services: health personnel, care-home workers and essential services such as the police and fire fighters, etc.<a class="elsevierStyleCrossRefs" href="#bib0650">6,56</a>The WHO recommend an annual vaccination coverage of at least 75% for those aged over 65 and for people at risk with chronic diseases, and to increase coverage for healthcare professionals and other risk groups.People over the age of 65 yearsPeople over the age of 65 are at more risk of serious complications due to age-related weakening of the immune system. In recent years, between 54% and 70% of hospitalisations and 71% to 85% of flu-related deaths occurred in people over the age of 65.<a class="elsevierStyleCrossRef" href="#bib0905">57</a> Therefore, influenza flu vaccination is indicated for this group.<a class="elsevierStyleCrossRefs" href="#bib0900">56,58–61</a>People with chronic diseases and immunodepressed peopleVaccination is recommended for a series of situations of chronic disease and immunosuppression that are shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Pregnant womenThe physiological changes specific to pregnancy increase the risk of influenza-related complications. Infection with the influenza virus also carries with it risks to the foetus that included preterm birth, low birth weight and an increased risk of death.<a class="elsevierStyleCrossRefs" href="#bib0895">55,62,63</a> The flu vaccine, given during pregnancy, protects both mother and child against the disease, and protects the newborn infant for several months after delivery.<a class="elsevierStyleCrossRefs" href="#bib0905">57,64,65</a> The WHO recognises pregnant women as a priority risk group.<a class="elsevierStyleCrossRefs" href="#bib0900">56,58–61</a>Other groups that should be vaccinatedPeople who live with people with high-risk diseasesAll those over the age of 6 months living with a person at risk should receive an annual influenza vaccine, according to the recommended guidelines,<a class="elsevierStyleCrossRef" href="#bib0870">50</a> for the indirect protection of that patient.Healthcare personnelThe term healthcare workers or personnel encompasses people who work, remunerated or otherwise, in the area of healthcare in direct contact with patients or with potentially infectious material, as well as all other health centre workers who, although in less contact with patients, are potentially exposed to the same infectious agents, regardless of their administrative relationship with the health centre.<a class="elsevierStyleCrossRef" href="#bib0950">66</a>These people are more exposed to immune preventable diseases and can transmit them to vulnerable people with whom they are in contact, therefore there should be maximal vaccine coverage for this group.<a class="elsevierStyleCrossRefs" href="#bib0900">56,58–61,67</a> Vaccinated health workers can see a rate of influenza in their environment reduced by 68% to 90% and days of absence from work reduced by 28% to 40%. Furthermore, the transmission of the virus from health personnel can be the source of care-related outbreaks, with up to 54.8% attack rates and up to 25% fatality, since these professionals are in contact with the abovementioned vulnerable groups. Finally, this group should set an example regarding the importance of vaccination and increase the trust of the general population in it. It is important to improve the poor vaccination coverage among health personnel (20–30%).<a class="elsevierStyleCrossRefs" href="#bib0915">59,66,68,69</a>Recommendations for influenza vaccination in SpainThe current influenza vaccination recommendations published by Spain's Ministry of Health, Consumer Affairs and Social Welfare<a class="elsevierStyleCrossRef" href="#bib0900">56</a> are shown in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>.<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>In addition to these, in the update and reflection document, the signatories propose amending and/or extending the vaccination recommendation to the following groups:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Everyone ≥60 years of age (not only from the age of 65), as a conservative measure to reduce the risk of influenza-related complications.</li><li class="elsevierStyleListItem" id="lsti0010">•All teaching staff, as part of the group delivering public services.</li><li class="elsevierStyleListItem" id="lsti0015">•Substance abusers, as a group at risk of suffering complications; especially intravenous drug users, at greater risk of immunosuppression and hepatitis and the human immunodeficiency virus, among others.</li><li class="elsevierStyleListItem" id="lsti0020">•Personnel working in direct contact with large groups, such as cruise-ship and flight crews, tour guides, etc.</li><li class="elsevierStyleListItem" id="lsti0025">•People who live in large groups in close-knit or semi-close knit environments, such as boarding schools, care-homes, halls of residence, ship crews, etc.</li><li class="elsevierStyleListItem" id="lsti0030">•Travellers who want to reduce their risk of infection with the influenza virus; who should consider vaccination preferably 2 weeks before they travel. In particular, people who are travelling during the influenza season (November to March in the northern hemisphere and April to September in the southern hemisphere), who have a risk factor for flu-related complications and who were not vaccinated in the previous season, and those who intend to travel in organised groups.</li></ul>It was also suggested that an official registry of influenza vaccination coverage should be established for pregnant women to enable access to data in our country. Finally, the recommendations on influenza vaccination for healthy children with no contraindications in other countries were reviewed,<a class="elsevierStyleCrossRefs" href="#bib0795">35,59–61,70</a> and it was considered that a debate should be started on the possibility in Spain of vaccination from the age of 6 months, and research proposals created, including cost-effectiveness, to determine its appropriateness.Strategies to increase vaccination coverageAlthough influenza vaccination is financed by the Public Health System in Spain, vaccination coverage has not reached the objective set by the WHO.<a class="elsevierStyleCrossRef" href="#bib0960">68</a> A global effort is required to increase vaccination coverage, especially among those at greater risk of the complications of the disease. All groups should be aware that influenza is a potentially serious and even fatal disease. It is necessary and urgent that we change the perception of health professionals and patients alike of the effectiveness and safety of the influenza vaccine, and healthcare professionals must set an example.<a class="elsevierStyleCrossRefs" href="#bib0655">7,71</a>The strategies proposed to increase vaccination coverage include the following<a class="elsevierStyleCrossRefs" href="#bib0965">69,71</a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035">•Implement information and training campaigns about influenza, its complications and the effectiveness and safety of the vaccine, targeting both the general population and health professionals.</li><li class="elsevierStyleListItem" id="lsti0040">•Design vaccination campaigns with the proactive inclusion of health workers as essential elements.</li><li class="elsevierStyleListItem" id="lsti0045">•Ensure easy access to vaccination: availability of vaccine, vaccination in clinics on demand and opportunistically, vaccination of health professionals in their work centre (health and safety at work) and study the possibility of giving the influenza vaccine in authorised pharmacies.</li><li class="elsevierStyleListItem" id="lsti0050">•Provide access to health professionals to information for any type of advice or query from vaccinated patients (website, e-mail, phone number, etc.).</li><li class="elsevierStyleListItem" id="lsti0055">•Use the media and new technologies, particularly social media, to broadcast the official indications for vaccination and communicate its importance according to risk groups and special situations.</li><li class="elsevierStyleListItem" id="lsti0060">•Effectively communicate the interest of the Health Departments in acquiring new and better influenza vaccines, in order to improve the perception of the general population on the effectiveness of influenza vaccination.</li><li class="elsevierStyleListItem" id="lsti0065">•Involve patient associations and associations for the elderly in spreading information and improving vaccination coverage.</li><li class="elsevierStyleListItem" id="lsti0070">•Use all the information that appears in Spanish scientific societies and by authors in our environment that encourages the spread of vaccination.</li><li class="elsevierStyleListItem" id="lsti0075">•Establish strategies that enable coverage to be measured in groups with special clinical conditions at high risk of complications and take advantage of any contact with the health system to recommend vaccination.</li></ul>ConclusionsInfluenza is an immune preventable disease that affects all population groups. It has major social and economic impact, although in most cases it is mild, it can have serious complications that require hospitalisation and can even cause death.Influenza vaccination is the most effective form of preventing the disease and its complications, significantly reducing the number of hospitalisations and deaths, especially among the most vulnerable, such as the elderly and other groups with risk factors. We now have increasingly safer and more effective vaccines. In addition to the usual trivalent vaccines or adjuvant vaccines, in recent years tetravalent vaccines have been developed that increase the level of protection without modifying the safety or immunogenicity profile.<a class="elsevierStyleCrossRefs" href="#bib0780">32–34</a> In general, there is poor perception of the risk of infection by the influenza virus and the severity of the disease, and there is a lack of precise information on the effectiveness of the vaccines, particularly among health personnel. It is necessary and urgent to raise the awareness and involve this group of professionals, as well as pharmacists (as information agents), so that they become vaccinated and recommend the vaccination. Similarly, it is important to optimise the participation of the media and explore and exploit the potential of the new technologies in conveying true information to the entire population. The scientific societies and associations for patients and the elderly can play an important role and their participation in training and conveying information should be encouraged. Access to influenza vaccination must be facilitated, and its benefits communicated.Conflict of interestThe medical writing support for this document was financed through a non-restricted contribution given by Sanofi-Aventis S.A. In activities unrelated to this paper, the authors declare that they have received financing or non-financial support from various companies: AG, from Pfizer, Sanofi-Pasteur and MSD; MFP, from Pfizer, Glaxo Smith Kline, Sanofi-Pasteur and Pfizer; JA, from Sanofi-Pasteur; DM, from Glaxo Smith Kline and Sanofi-Pasteur; ER, from Glaxo Smith Kline, Sanofi-Pasteur, Pfizer, Novartis and MSD; IJ, from Pfizer; MGC, from Sanofi-Pasteur, Glaxo Smith Kline, Pfizer and MSD; JALP, from Sanofi-Pasteur and Pfizer." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres1142656" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1073300" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1142655" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1073301" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Presentation" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Introduction to influenza" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "The influenza virus types" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Transmission" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical features and symptoms" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Economic and social impact of influenza" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Mortality" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Economic impact" ] ] ] 7 => array:3 [ "identificador" => "sec0045" "titulo" => "Influenza vaccination and its benefits" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Types of influenza vaccines" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Effectiveness" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Safety" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Vaccines available in Spain" ] 4 => array:2 [ "identificador" => "sec0070" "titulo" => "Contraindications and precautions" ] ] ] 8 => array:3 [ "identificador" => "sec0075" "titulo" => "Risk groups" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "People over the age of 65 years" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "People with chronic diseases and immunodepressed people" ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Pregnant women" ] 3 => array:3 [ "identificador" => "sec0095" "titulo" => "Other groups that should be vaccinated" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0100" "titulo" => "People who live with people with high-risk diseases" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Healthcare personnel" ] ] ] ] ] 9 => array:2 [ "identificador" => "sec0110" "titulo" => "Recommendations for influenza vaccination in Spain" ] 10 => array:2 [ "identificador" => "sec0115" "titulo" => "Strategies to increase vaccination coverage" ] 11 => array:2 [ "identificador" => "sec0120" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0125" "titulo" => "Conflict of interest" ] 13 => array:2 [ "identificador" => "xack389350" "titulo" => "Acknowledgements" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-09-28" "fechaAceptado" => "2018-10-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1073300" "palabras" => array:3 [ 0 => "Influenza" 1 => "Vaccination" 2 => "Recommendations" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1073301" "palabras" => array:3 [ 0 => "Gripe" 1 => "Vacunación" 2 => "Recomendaciones" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Influenza is the most common infectious disease preventable by vaccination in developed countries; it can affect people of all ages and cause epidemics. Although the symptoms are usually mild, complications may arise that require a hospital admission and might cause the patient's death in some cases. Vaccination is the most effective way to prevent influenza, and the World Health Organization recommends reaching immunization coverages against influenza of at least 75% in people over 65 years of age and in the high-risk population, as well as among healthcare professionals. This document summarizes the key points of a recent document containing information updates and considerations regarding influenza vaccination in Spain and the present recommendations. The document was issued by the Influenza Study Group and the signing scientific societies and professional organizations." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La gripe es la enfermedad infecciosa, prevenible mediante vacunación, más frecuente en los países desarrollados, y puede afectar a personas de todas las edades y dar lugar a epidemias. Aunque la sintomatología habitualmente es leve, pueden aparecer complicaciones que requieran ingreso hospitalario y causar en algunos casos la muerte del paciente. La vacunación es la forma más efectiva de prevenirla y la Organización Mundial de la Salud recomienda alcanzar una cobertura vacunal frente a la gripe de al menos el 75% en personas mayores de 65 años y en la población de alto riesgo, así como en los profesionales sanitarios. Este documento resume los puntos fundamentales de un trabajo de actualización y reflexión sobre la vacunación antigripal en España y las recomendaciones al respecto, que realizaron el Grupo de Estudio de la Gripe y las sociedades científicas y organizaciones profesionales firmantes." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: García A, Fernández-Prada M, Aristegui J, Moreno D, Redondo E, Jimeno I, et al. Resumen ejecutivo del documento de actualización y reflexión sobre vacunación antigripal en España. Vacunas. 2018;19:85–98." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "This document is the executive summary of the Executive summary of the update and reflection document on influenza vaccination in Spain, endorsed by the Spanish Vaccinology Association (AEV), Spanish Paediatric Association (AEP), Spanish Society of Primary Care Physicians (SEMERGEN), Spanish Society of General and Family Physicians (SEMG), Spanish Society of Preventive Medicine, Public Health and Hygiene (SEMPSPH) and the Spanish Society of Geriatrics and Gerontology (SEGG)." ] ] "multimedia" => array:6 [ 0 => 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:2 [ "leyenda" => "Adapted from Ortiz de Lejarazu and Tamames.<a class="elsevierStyleCrossRef" href="#bib0655">7</a>" "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Composition \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Trivalent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Tetravalent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Properties \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="7" align="left" valign="top">Inactivated</td><td class="td" title="table-entry " align="left" valign="top">Complete viruses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">More reactogenic, some adverse reactions<a class="elsevierStyleCrossRefs" href="#bib0720">20,31</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Split viruses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Less reactogenic, few adverse reactions<a class="elsevierStyleCrossRefs" href="#bib0720">20,31</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Viral subunits (HA and NA) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Highly purified \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adjuvanted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Greater antigenic response or protection spectrum Important role in immunising people over the age of 65<a class="elsevierStyleCrossRefs" href="#bib0980">72–74</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Virosomal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Greater antigenic response or protection spectrum Simulate the structure and arrangement of the whole virion<a class="elsevierStyleCrossRefs" href="#bib0995">75,76</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intradermal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Enter into direct contact with the Langerhans cells and the dendritic skin cells, which results in greater immunogenicity<a class="elsevierStyleCrossRef" href="#bib1005">77</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prepared in cell cultures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No preservatives or antibiotics Less likelihood of mismatch between the vaccine and circulating strains.<a class="elsevierStyleCrossRefs" href="#bib0765">29,78,79</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Live-attenuated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cold-adapted Restricted growth at>37°C Restricted growth in the upper respiratory tract<a class="elsevierStyleCrossRefs" href="#bib0655">7,80</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">√ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Greater antigenic response \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1949990.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Types of live-attenuated or inactivated influenza vaccines." ] ] 1 => 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:3 [ "leyenda" => "In bold, the strain chosen for the season's trivalent vaccine." "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Season \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">A(H1N1)pdm \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">A(H3N2) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">B(Victoria) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">B(Yamagata) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Most prevalent B strain lineage in Spain \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mismatch between vaccine strain and most prevalent B strain \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2007–2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Solomon Islands/3/2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Wisconsin/67/2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Malaysia/2506/2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yamagata \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">● \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2008–2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Brisbane/59/2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Brisbane/10/2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Florida/4/2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Victoria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">● \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2009–2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Brisbane/59/2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Brisbane/10/2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Brisbane/60/2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Victoria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">20010–2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/California/7/2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Perth/16/2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Brisbane/60/2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Victoria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2011–2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/California/7/2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Perth/16/2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Brisbane/60/2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yamagata \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">● \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2012–2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/California/7/2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Victoria/361/2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Wisconsin/1/2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yamagata \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2013–2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Christchurch/16/2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Texas/50/2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Brisbane/33/2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Massachusetts/2/2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yamagata \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">●<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2014–2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/California/7/2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Texas/50/2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Brisbane/60/2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Massachusetts/2/2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yamagata \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2015–2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/California/7/2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Switzerland/9715293/2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Brisbane/60/2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Phuket/3073/2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Victoria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">● \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2016–2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/California/7/2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Hong Kong/4801/2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Brisbane/60/2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Phuket/3073/2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Victoria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2017–2018 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Michigan/45/2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A/Hong Kong/4801/2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Brisbane/60/2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B/Phuket/3073/2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yamagata \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">● \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1949988.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "In this 2013–2014 season Yamagata and Victoria co-circulated, therefore there was partial mismatch. Source: Table constructed with the data from the WHO annual recommendations,<a class="elsevierStyleCrossRef" href="#bib0860">48</a> data from the reports of season ISCIII.<a class="elsevierStyleCrossRef" href="#bib0740">24</a>" ] ] ] "descripcion" => array:1 [ "en" => "Composition recommended by the WHO for the trivalent and tetravalent influenza vaccines over the past 10 seasons and predominant B strain/lineage in Spain during that season." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "PF: pharmaceutical form; I: intranasal; ID: intradermal delivery; IM: intramuscular; PS: preloaded syringe; S: suspension; IS: injectable suspension; DSI: deep subcutaneous injection.Source: CIMA.<a class="elsevierStyleCrossRef" href="#bib1025">81</a>" "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Name \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PF/presentation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Laboratory \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Immunogen \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Route \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afluria® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IS/PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Seqirus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trivalent/split/inactivated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥5 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IM/DSI \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chiroflu® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IS/PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Seqirus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trivalent/surface antigen/inactivated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IM/DSI \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chiromas® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IS/PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Seqirus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trivalent/surface antigen/inactivated/adjuvant MF59C.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IM \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Influvac® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IS/PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mylan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trivalent/surface antigen/inactivated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IM/DSI \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intanza® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IS/PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sanofi Pasteur Europe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trivalent/split/inactivated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥60 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ID \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mutagrip® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IS/PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sanofi Pasteur Europe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trivalent/split/inactivated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IM/DSI \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaxigrip® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IS/PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sanofi Pasteur Europe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trivalent/split/inactivated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IM/DSI \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluarix Tetra® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IS/PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GlaxoSmithKline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tetravalent/split/inactivated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥3 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IM \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaxigrip Tetra® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IS/PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sanofi Pasteur Europe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tetravalent/split/inactivated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IM/DSI \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluenz Tetra® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S/I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Astra Zeneca \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tetravalent/whole virions/attenuated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 to 18 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1949991.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Authorised influenza vaccines in Spain." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "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="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Contraindication/precaution \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Temporary situations</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pregnancy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Live-attenuated vaccines should not be used \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunodepression or immunosuppression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Live attenuated vaccines should not be used (injected or intranasal) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Any moderate or severe disease<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> with or without fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No vaccination should be given in general, except in situations of extremely high epidemic risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Under the age of 18 and treated with salicylates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intranasal live-attenuated vaccine should not be used<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Under the age of 18 with severe asthma or active wheezing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intranasal live-attenuated vaccine should not be used<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Under the age of 6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Influenza vaccine should not be given \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Precautions</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">There should be no vaccination in general, until it subsides \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">History of Guillain-Barré syndrome in the 6 months after administration of a vaccine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Carefully assess whether or not it is appropriate to give a dose after this vaccine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intranasal<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> administration of live-attenuated agents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Avoid contact with severely immunodepressed people for 1.2 weeks after vaccination \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1949993.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "For example, asthma attack, decompensated heart disease, acute diarrhoea, etc." ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "b" "nota" => "Authorised, but not marketed in Spain.<a class="elsevierStyleCrossRef" href="#bib1030">82</a>" ] ] ] "descripcion" => array:1 [ "en" => "Temporary contraindications and precautions with the influenza vaccination." ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "COPD: chronic obstructive pulmonary disease; HIV: human immunodeficiency virus." "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Population group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Notes \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Immunodepressed people</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Primary immunodepression (hereditary or genetic disorders) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Immunodepression in general is an important risk factor for contracting flu and developing complications<a class="elsevierStyleCrossRefs" href="#bib1035">83,84</a> The attenuated vaccines are completely contraindicated in the case of severe immunodepression. Inactivated vaccines should be used<a class="elsevierStyleCrossRef" href="#bib0900">56</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Secondary immunodepression (disease acquired or drug-induced immunodeficiency) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Immunodepression in general is an important risk factor for contracting flu and developing complications<a class="elsevierStyleCrossRefs" href="#bib1035">83,84</a> The influenza vaccines are effective for HIV-infected people, although the benefit is reduced in the case of advanced disease<a class="elsevierStyleCrossRefs" href="#bib1045">85,86</a> The attenuated vaccines are completely contraindicated in the case of severe immunodepression. Inactivated vaccines should be used<a class="elsevierStyleCrossRef" href="#bib0900">56</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Chronic diseases</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rheumatic diseases (whether or not treated with immunosuppressants and/or disease modifying drugs) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients with rheumatoid arthritis suffer a greater burden of infectious disease-related morbidity and mortality and have double the risk of contracting a severe infection than that of the general population. This is associated with autoimmune disease as well as the immunosuppressive therapies that are commonly used for this population<a class="elsevierStyleCrossRef" href="#bib1055">87</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cystic fibrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">It is particularly important to avoid diseases that cause lung deterioration such as influenza or pneumonia<a class="elsevierStyleCrossRef" href="#bib1060">88</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic cardiovascular diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Carry a high risk of complications, hospitalisation and death due to the flu virus<a class="elsevierStyleCrossRefs" href="#bib1065">89–91</a> Inflammatory response and viral infection induce the production of autoantibodies against low density lipoproteins, causing the development and progression of atherosclerotic vascular lesions Direct colonisation of the vessel wall starts local autoimmune reactions, by the activation of antigen-presenting cells Vaccination has a major protective effect in patients with prior heart disease, especially acute myocardial infarction, reducing the mortality rate due to influenza by >60%<a class="elsevierStyleCrossRef" href="#bib1070">90</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic neurological and neuromuscular diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Increase the risk of complications due to disorders that compromise normal lung function and secretory capacity<a class="elsevierStyleCrossRefs" href="#bib1080">92,93</a> Due to reduced muscle power for inspiration and expiration Reduced muscle tone, reduced mobility Structural physical conditions, such as scoliosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic lung disease (COPD, asthma) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Most COPD exacerbations are caused by respiratory infections, although there are other factors<a class="elsevierStyleCrossRef" href="#bib1090">94</a> Influenza is more common and has more complications in patients with acute respiratory disorders such as COPD and asthma.<a class="elsevierStyleCrossRefs" href="#bib1095">95,96</a> The influenza vaccine is effective in this group and its effects are even greater when given to elderly people.<a class="elsevierStyleCrossRefs" href="#bib1090">94,97–99</a> Various organisations recommend vaccination for this group<a class="elsevierStyleCrossRefs" href="#bib0740">24,56,58–61</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metabolic diseases (including diabetes mellitus) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hyperglycaemia in diabetic patients weakens the immune system, increasing susceptibility to infections, while these in turn can increase glycaemia<a class="elsevierStyleCrossRefs" href="#bib1120">100,101</a> The vaccine reduces the complications as well as the mortality associated with the disease<a class="elsevierStyleCrossRefs" href="#bib0855">47,102–107</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Morbid obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">This group has a higher rate of admissions than the normal population and poorer disease outcome.<a class="elsevierStyleCrossRef" href="#bib1160">108</a> The international guidelines include morbid obesity on the list of vaccination recommendations<a class="elsevierStyleCrossRefs" href="#bib0875">51,56,58,60,61,109,110</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic kidney failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Is usually associated with a degree of immunosuppression, comorbidities such as hypertension or diabetes, and common in advanced age Since 2015, stage 3b (of 5) patients have been expressly included, with a glomerular filtration rate of 30–45ml/min/1.73m2<a class="elsevierStyleCrossRef" href="#bib1175">111</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaemia and haemoglobinopathies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Influenza (especially caused by the H1N1 virus) is often severe in this case, mainly among the elderly,<a class="elsevierStyleCrossRef" href="#bib1180">112</a> and carries an increased risk of hospitalisation<a class="elsevierStyleCrossRef" href="#bib1185">113</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asplenia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Various studies demonstrate that the influenza vaccine can reduce the risk of death by 54% in asplenic patients<a class="elsevierStyleCrossRefs" href="#bib1040">84,114,115</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic liver disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Influenza can be a cause of liver decompensation in cirrhosis patients.<a class="elsevierStyleCrossRefs" href="#bib1040">84,116</a> Annual vaccination as a principal strategy to reduce the complications and mortality caused by influenza<a class="elsevierStyleCrossRefs" href="#bib0900">56,58–61,117</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vaccination is especially recommended for certain types of cancer that affect the bone marrow, such as leukaemias, multiple myeloma or lymphoma. The immunosuppression caused by antitumour treatments should also be considered.<a class="elsevierStyleCrossRef" href="#bib1210">118</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Down's syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Immunological anomalies are common in the humoral and cellular compartments and there is high morbidity and mortality due to infectious diseases, especially of the respiratory tract and particularly in the first 5 years of life, and at more advanced ages. <a class="elsevierStyleCrossRefs" href="#bib1215">119,120</a> Influenza vaccination is strongly recommended<a class="elsevierStyleCrossRefs" href="#bib1225">121,122</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Other</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cochlear implantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Implanted patients are at more risk of severe infections, such as meningitis and otitis media, which can be secondary to infection with the influenza virus<a class="elsevierStyleCrossRefs" href="#bib1040">84,123,124</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatric patients under treatment with salicylates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Annual influenza vaccination is recommended from the age of 6 months, to reduce the risk of Reye's syndrome. Intranasal attenuated vaccine should not be given (not marketed in Spain). Moreover, allow 4 weeks before starting treatment with salicylates in paediatric patients vaccinated with live viruses<a class="elsevierStyleCrossRef" href="#bib0870">50</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1949989.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Chronic diseases and immunodepression disorders where influenza vaccination is recommended." ] ] 5 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "HIV: human immunodeficiency virus." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. People over the age of 65. Especially if living together in institutions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. People under the age of 65 at high risk of influenza-related complications<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2.1. Children (over the age of 6 months) and adults with chronic cardiovascular disease (excluding isolated arterial hypertension), neurological or lung disease, including bronchopulmonary dysplasia, cystic fibrosis and asthma. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2.2. Children (over the age of 6 months) and adults with: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metabolic diseases, including diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Morbid obesity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kidney failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemoglobinopathies and anaemias \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asplenia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic liver disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe neuromuscular diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunosuppression (including due to HIV or drugs) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cancer \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rheumatic diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cochlear implant or awaiting implantation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disorders and diseases that involve cognitive dysfunction: Down's syndrome, dementia and others \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2.3. Children and adolescents, from 6 months to 18 years, receiving prolonged treatment with acetylsalicylic acid, due to the possibility of developing Reye's syndrome after influenza \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2.4. Women in any trimester of pregnancy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. People who might transmit influenza to others with a risk of complications: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3.1. Workers in health centres, services and establishments. Particularly health professionals caring for patients in the high risk groups of point 2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3.2. People working in geriatric institutions or care centres for chronically ill patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3.3. Work placement students in healthcare centres \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3.4. People who provided domiciliary care for patients at high risk or the elderly \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3.5. People over the age of 6 months living in the same home as others from any of the high risk groups of point 2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Other groups for whom vaccination is recommended: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4.1. People working in the essential public services. Particularly: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The national, regional or local law-enforcement and security agencies of the State \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fire fighters \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Civil protection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Health emergency services \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Penal institutions and other related detention facilities \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4.2. Workers who are directly exposed to poultry or pigs in farms or poultry or pig farming industries, and wild birds \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1949992.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "Special emphasis will be placed in this group on those requiring periodic medical follow-up or who have been hospitalised in the preceding year. Those under the age of 65 who live together in institutions should also be considered. 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Scientific Societies Consensus

Executive summary of the update and reflection document on influenza vaccination in Spain

Resumen ejecutivo del documento de actualización y reflexión sobre vacunación antigripal en España

A. Garcíaa,

Corresponding author

agarroj@gobiernodecanarias.org

Corresponding author.

, M. Fernández-Pradaa, J. Aristeguib, D. Morenob, E. Redondoc, I. Jimenod, M. García Cenoze, J.A. Lopez Trigof

a Asociación Española de Vacunología, Spain

b Asociación Española de Pediatría, Spain

c Sociedad Española de Médicos de Atención Primaria, Spain

d Sociedad Española de Médicos Generales y de Familia, Spain

e Sociedad Española de Medicina Preventiva, Salud Pública e Higiene, Spain

f Sociedad Española de Geriatría y Gerontología, Spain

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to reduce the major health and social burden of seasonal influenza on the population&#44; especially the most vulnerable groups&#46; The Influenza Study Group and the signatory scientific societies and professional organisations have drawn up a document on influenza vaccination&#44; detailing the scientific evidence behind its benefits&#44; particularly for certain sectors of the population&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">3</span></a> The aim is to contribute to meeting the recommendations of the World Health Organisation &#40;WHO&#41; and achieve influenza vaccination coverage of at least 75&#37; among people over the age of 65 and those at high risk&#44;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">4</span></a> as well as healthcare professionals&#46; This executive summary brings together the essential aspects of this document&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction to influenza</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">The influenza virus types</span><p id="par0015" class="elsevierStylePara elsevierViewall">The influenza virus is classified into 3 types&#58; A&#44; B and C &#40;although there is evidence of a fourth type&#44; D<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">5</span></a>&#41;&#46; Types A and B are responsible for most cases of infection in human beings and cause seasonal epidemia&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">6</span></a> Two subtypes of virus A &#40;H1N1&#41; and A&#40;H3N2&#41;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">7</span></a> are currently circulating in the population&#44; and 2 type B virus lineages&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The A virus has been responsible for all known pandemics&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">1&#44;8</span></a> It has important rates of spontaneous mutation&#44; which causes changes in its genome&#44;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">9</span></a> which in turn results in the appearance of new viral strains&#46; It is the appearance of these new viral subtypes that can cause pandemic outbreaks&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">6&#44;10&#8211;12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Two lineages of the B influenza virus &#40;B&#47;Yamagata and B&#47;Victoria&#41; have been co-circulating since the mid-nineteen eighties that are antigenically and phylogenetically distinct&#46;<a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">13&#44;14</span></a> Infants and young adults are most commonly affected by influenza B disease&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">15</span></a> Although the influenza A virus &#40;H3N2&#41; has been related to higher rates of hospitalisation and death&#44; major morbidity and mortality are associated with the type B virus which&#44; in general&#44; exceed those of subtype A&#40;H1N1&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">13&#44;16&#44;17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Transmission</span><p id="par0030" class="elsevierStylePara elsevierViewall">Influenza is mainly transmitted by close contact &#40;1&#8211;2<span class="elsevierStyleHsp" style=""></span>m&#41; through droplets expelled by coughing or sneezing&#46; It can also be spread by contact with surfaces&#44; objects or hands that have been contaminated by respiratory secretions&#46; The transmissibility period of an infected person is from 24<span class="elsevierStyleHsp" style=""></span>h to 48<span class="elsevierStyleHsp" style=""></span>h before symptoms appear until 5 days afterwards&#46; Children&#44; the elderly and immunosuppressed people can be contagious for longer &#40;up to 7&#8211;10 days afterwards&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical features and symptoms</span><p id="par0035" class="elsevierStylePara elsevierViewall">Initial clinical symptoms are usually sudden in onset with fever and chills&#44; accompanied by headache&#44; nasal congestion&#44; sore throat&#44; general malaise&#44; muscle pain&#44; loss of appetite and dry cough&#46;<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">2&#44;6</span></a> The current definition for influenza is that proposed by the European Union&#58; &#8220;sudden onset of symptoms and at least one of the following four systemic symptoms&#58; fever or feverishness&#44; malaise&#44; headache&#44; myalgia&#59; and at least one of the following three respiratory symptoms&#58; cough&#44; sore throat&#44; shortness of breath&#44; as well as the absence of other diagnostic suspicion&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">18</span></a> The secondary diseases most commonly associated with influenza are pneumonia&#44; bronchitis&#44; sinusitis and otitis&#44; and exacerbation of other pre-existing chronic diseases&#46; Severe infections can cause heart problems&#44; meningitis&#44; encephalitis or meningoencephalitis&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">2</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Economic and social impact of influenza</span><p id="par0040" class="elsevierStylePara elsevierViewall">Influenza presents in the form of seasonal epidemic outbreaks&#46; These occur in the winter months in Spain &#40;generally from November to March&#41; and most cases appear over a 6&#8211;8 week time frame&#46; However&#44; the start of this period and the extension and severity of each epidemic vary from one year to another&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">1</span></a></p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Mortality</span><p id="par0045" class="elsevierStylePara elsevierViewall">A recent modelling study&#44; with data from 33 countries from 1999 until 2015&#44; indicated that influenza-related respiratory mortality might account for 291&#44;243 and 645&#44;832 annual deaths &#40;4&#46;0&#8211;8&#46;8 deaths per 100&#44;000 inhabitants&#41;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">19</span></a>&#59; these are the figures used by the WHO since 2017&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">20</span></a> The disease particularly affects the paediatric population &#40;2&#46;1 and 23&#46;8 annual deaths per 100&#44;000&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">19</span></a> although the most severe cases are principally people over the age of 65 &#40;2&#46;9&#8211;44&#46;0 and 17&#46;9&#8211;223 deaths per 100&#44;000 inhabitants among those aged from 65 to 75 and those aged over 75&#44; respectively&#41;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">19</span></a> and people with chronic illnesses&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">1&#44;2&#44;21&#8211;23</span></a> In Spain&#44; in the last 5 seasons&#44; most of the influenza outbreaks took place in geriatric care homes&#44; where up to 80&#37; of cases occurred in the season 2016&#8211;2017&#44; healthcare centres and other similar institutions&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">24</span></a> Three thousand one hundred and one &#40;11&#46;4&#37; of deaths&#41; confirmed&#44; hospitalised cases of severe influenza were reported to the Spanish Influenza Surveillance System in the season 2015&#8211;2016&#46; It is worth highlighting that of the people who were hospitalised or who died due to the disease in the season 2016&#8211;2017&#44; only 52&#37; who belonged to groups for whom influenza vaccination is recommended had been vaccinated&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Economic impact</span><p id="par0050" class="elsevierStylePara elsevierViewall">There is a considerable increase in care demand during the influenza season&#46; The costs associated with an influenza season in a country like Spain can exceed 1000 million Euros&#46;<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">25&#44;26</span></a> A quarter of this amount is for direct costs&#59; the remainder covers labour costs&#46; On average&#44; every case of influenza results in 5&#8211;6 days of limited activity&#44; 3&#8211;4 days of restricted activity&#47;bed rest&#44; and around 3 days of absence from work&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">27</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Influenza vaccination and its benefits</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Types of influenza vaccines</span><p id="par0055" class="elsevierStylePara elsevierViewall">The influenza vaccines are classified into 2 large groups&#58; &#40;i&#41; inactivated flu vaccines and &#40;ii&#41; live attenuated vaccines&#46; Some can be used from the age of 6 months&#44; but others are indicated for specific age groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0655"><span class="elsevierStyleSup">7&#44;28&#8211;31</span></a> The current vaccination campaigns in Spain mainly use the trivalent vaccines &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Tetravalent split-virus vaccines have been developed in recent years&#44; containing 2 B virus strains&#44; one of each lineage&#44; in order to avoid mismatch between the B vaccine strain and the B strain circulating in each season&#46; The tetravalent vaccines increase the level of protection without modifying the safety or immunogenicity profile&#44; compared to the trivalent vaccines&#46; These advantages might make these the gold standard in influenza prevention in the near future&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">32&#8211;34</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Effectiveness</span><p id="par0060" class="elsevierStylePara elsevierViewall">Influenza vaccination is the most effective way of preventing the disease and its complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">32&#44;35&#8211;37</span></a> Due to the antigenic drift&#44; the influenza vaccine is reformulated every year to adjust to the type of virus that is expected to be circulating that season&#44; therefore there is some uncertainty as to effectiveness every year&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">7</span></a> The vaccine&#39;s effectiveness varies for different reasons&#59; some inherent to its design&#44; such as the match or mismatch between the strains in the vaccine and that year&#39;s circulating strains&#59; the type of vaccine &#8211; attenuated or inactivated &#8211; or the administration route&#59; but the features of the virus and of the individual vaccinated also have an influence&#46;<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">20&#44;38</span></a> In general&#44; and without going into this variability&#44; overall effectiveness is around 65&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0655"><span class="elsevierStyleSup">7&#44;39</span></a> In studies from the nineteen eighties&#44; 30&#8211;74&#37; protection has been documented for healthy young people &#8211; adults&#44; and 42&#8211;72&#37; for people over the age of 59&#44; depending on the season&#46;<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">40</span></a> Likewise&#44; it is estimated that the number of hospitalisations due to pneumonia of people over the age of 65 is reduced by almost 80&#37;&#44; and the mortality of people over the age of 75 with chronic illnesses is reduced by approximately 22&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">41&#8211;43</span></a> Various authors have indicated that the seasonal tetravalent vaccine would increase protection reducing the problems associated with mismatch&#46;<a class="elsevierStyleCrossRefs" href="#bib0655"><span class="elsevierStyleSup">7&#44;13&#44;15&#44;44&#8211;47</span></a> Over the past 10 seasons there has been mismatch between the circulating B strain and the vaccine content on 5 occasions &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Safety</span><p id="par0065" class="elsevierStylePara elsevierViewall">The inactivated influenza vaccines have excellent profiles of safety and adverse events&#59; if they do occur&#44; they are usually mild local or systemic&#46; More than 300 million doses are distributed every year and major side effects are extremely rare with any type of influenza virus&#46;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Vaccines available in Spain</span><p id="par0070" class="elsevierStylePara elsevierViewall">Trivalent and tetravalent vaccines are currently available in Spain &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; They all have the same influenza virus strains in each season&#44; those recommended by the WHO and the European Union each year<a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">13&#44;48&#44;49</span></a>&#58; 2 A strains and 2 B strains&#44; one from each lineage&#44; for the tetravalents&#44; and the B strain specifically selected for the trivalents&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Contraindications and precautions</span><p id="par0075" class="elsevierStylePara elsevierViewall">The features of the individual that increase their risk of an adverse reaction and the precautions to be taken to minimise this risk should be known&#46; Before vaccination the patient should be checked for any contraindications or whether a precaution should be taken&#44;<a class="elsevierStyleCrossRefs" href="#bib0795"><span class="elsevierStyleSup">35&#44;50&#44;51</span></a> checking the updated version of the vaccine&#39;s datasheet &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; International committees of experts consider that an egg allergy is no longer a contraindication for the influenza vaccine&#44; although it is included on the influenza vaccine datasheets in Spain&#46;<a class="elsevierStyleCrossRefs" href="#bib0795"><span class="elsevierStyleSup">35&#44;52</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Risk groups</span><p id="par0080" class="elsevierStylePara elsevierViewall">Although the general population is vulnerable to infection by the influenza virus&#44; there are groups that are more likely to transmit the virus to others&#44; to develop complications or even die as a consequence of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">53</span></a> The health authorities recommend vaccination against influenza particularly for those at greater risk of presenting complications&#46; This group includes those aged over 65&#44; the chronically sick&#44; immunosuppressed people and pregnant women&#46;<a class="elsevierStyleCrossRefs" href="#bib0885"><span class="elsevierStyleSup">53&#8211;55</span></a> In addition&#44; vaccination is recommended for people who might transmit the disease to others at high risk of complications and those who&#44; due to their occupation&#44; provide essential community services&#58; health personnel&#44; care-home workers and essential services such as the police and fire fighters&#44; etc&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">6&#44;56</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The WHO recommend an annual vaccination coverage of at least 75&#37; for those aged over 65 and for people at risk with chronic diseases&#44; and to increase coverage for healthcare professionals and other risk groups&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">People over the age of 65 years</span><p id="par0090" class="elsevierStylePara elsevierViewall">People over the age of 65 are at more risk of serious complications due to age-related weakening of the immune system&#46; In recent years&#44; between 54&#37; and 70&#37; of hospitalisations and 71&#37; to 85&#37; of flu-related deaths occurred in people over the age of 65&#46;<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">57</span></a> Therefore&#44; influenza flu vaccination is indicated for this group&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">56&#44;58&#8211;61</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">People with chronic diseases and immunodepressed people</span><p id="par0095" class="elsevierStylePara elsevierViewall">Vaccination is recommended for a series of situations of chronic disease and immunosuppression that are shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Pregnant women</span><p id="par0100" class="elsevierStylePara elsevierViewall">The physiological changes specific to pregnancy increase the risk of influenza-related complications&#46; Infection with the influenza virus also carries with it risks to the foetus that included preterm birth&#44; low birth weight and an increased risk of death&#46;<a class="elsevierStyleCrossRefs" href="#bib0895"><span class="elsevierStyleSup">55&#44;62&#44;63</span></a> The flu vaccine&#44; given during pregnancy&#44; protects both mother and child against the disease&#44; and protects the newborn infant for several months after delivery&#46;<a class="elsevierStyleCrossRefs" href="#bib0905"><span class="elsevierStyleSup">57&#44;64&#44;65</span></a> The WHO recognises pregnant women as a priority risk group&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">56&#44;58&#8211;61</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Other groups that should be vaccinated</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">People who live with people with high-risk diseases</span><p id="par0105" class="elsevierStylePara elsevierViewall">All those over the age of 6 months living with a person at risk should receive an annual influenza vaccine&#44; according to the recommended guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">50</span></a> for the indirect protection of that patient&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Healthcare personnel</span><p id="par0110" class="elsevierStylePara elsevierViewall">The term healthcare workers or personnel encompasses people who work&#44; remunerated or otherwise&#44; in the area of healthcare in direct contact with patients or with potentially infectious material&#44; as well as all other health centre workers who&#44; although in less contact with patients&#44; are potentially exposed to the same infectious agents&#44; regardless of their administrative relationship with the health centre&#46;<a class="elsevierStyleCrossRef" href="#bib0950"><span class="elsevierStyleSup">66</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">These people are more exposed to immune preventable diseases and can transmit them to vulnerable people with whom they are in contact&#44; therefore there should be maximal vaccine coverage for this group&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">56&#44;58&#8211;61&#44;67</span></a> Vaccinated health workers can see a rate of influenza in their environment reduced by 68&#37; to 90&#37; and days of absence from work reduced by 28&#37; to 40&#37;&#46; Furthermore&#44; the transmission of the virus from health personnel can be the source of care-related outbreaks&#44; with up to 54&#46;8&#37; attack rates and up to 25&#37; fatality&#44; since these professionals are in contact with the abovementioned vulnerable groups&#46; Finally&#44; this group should set an example regarding the importance of vaccination and increase the trust of the general population in it&#46; It is important to improve the poor vaccination coverage among health personnel &#40;20&#8211;30&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">59&#44;66&#44;68&#44;69</span></a></p></span></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Recommendations for influenza vaccination in Spain</span><p id="par0120" class="elsevierStylePara elsevierViewall">The current influenza vaccination recommendations published by Spain&#39;s Ministry of Health&#44; Consumer Affairs and Social Welfare<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">56</span></a> are shown in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">In addition to these&#44; in the <span class="elsevierStyleItalic">update and reflection document</span>&#44; the signatories propose amending and&#47;or extending the vaccination recommendation to the following groups&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Everyone &#8805;60 years of age &#40;not only from the age of 65&#41;&#44; as a conservative measure to reduce the risk of influenza-related complications&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">All teaching staff&#44; as part of the group delivering public services&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Substance abusers&#44; as a group at risk of suffering complications&#59; especially intravenous drug users&#44; at greater risk of immunosuppression and hepatitis and the human immunodeficiency virus&#44; among others&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Personnel working in direct contact with large groups&#44; such as cruise-ship and flight crews&#44; tour guides&#44; etc&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">People who live in large groups in close-knit or semi-close knit environments&#44; such as boarding schools&#44; care-homes&#44; halls of residence&#44; ship crews&#44; etc&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Travellers who want to reduce their risk of infection with the influenza virus&#59; who should consider vaccination preferably 2 weeks before they travel&#46; In particular&#44; people who are travelling during the influenza season &#40;November to March in the northern hemisphere and April to September in the southern hemisphere&#41;&#44; who have a risk factor for flu-related complications and who were not vaccinated in the previous season&#44; and those who intend to travel in organised groups&#46;</p></li></ul></p><p id="par0160" class="elsevierStylePara elsevierViewall">It was also suggested that an official registry of influenza vaccination coverage should be established for pregnant women to enable access to data in our country&#46; Finally&#44; the recommendations on influenza vaccination for healthy children with no contraindications in other countries were reviewed&#44;<a class="elsevierStyleCrossRefs" href="#bib0795"><span class="elsevierStyleSup">35&#44;59&#8211;61&#44;70</span></a> and it was considered that a debate should be started on the possibility in Spain of vaccination from the age of 6 months&#44; and research proposals created&#44; including cost-effectiveness&#44; to determine its appropriateness&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Strategies to increase vaccination coverage</span><p id="par0165" class="elsevierStylePara elsevierViewall">Although influenza vaccination is financed by the Public Health System in Spain&#44; vaccination coverage has not reached the objective set by the WHO&#46;<a class="elsevierStyleCrossRef" href="#bib0960"><span class="elsevierStyleSup">68</span></a> A global effort is required to increase vaccination coverage&#44; especially among those at greater risk of the complications of the disease&#46; All groups should be aware that influenza is a potentially serious and even fatal disease&#46; It is necessary and urgent that we change the perception of health professionals and patients alike of the effectiveness and safety of the influenza vaccine&#44; and healthcare professionals must set an example&#46;<a class="elsevierStyleCrossRefs" href="#bib0655"><span class="elsevierStyleSup">7&#44;71</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The strategies proposed to increase vaccination coverage include the following<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">69&#44;71</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Implement information and training campaigns about influenza&#44; its complications and the effectiveness and safety of the vaccine&#44; targeting both the general population and health professionals&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Design vaccination campaigns with the proactive inclusion of health workers as essential elements&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Ensure easy access to vaccination&#58; availability of vaccine&#44; vaccination in clinics on demand and opportunistically&#44; vaccination of health professionals in their work centre &#40;health and safety at work&#41; and study the possibility of giving the influenza vaccine in authorised pharmacies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Provide access to health professionals to information for any type of advice or query from vaccinated patients &#40;website&#44; e-mail&#44; phone number&#44; etc&#46;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Use the media and new technologies&#44; particularly social media&#44; to broadcast the official indications for vaccination and communicate its importance according to risk groups and special situations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Effectively communicate the interest of the Health Departments in acquiring new and better influenza vaccines&#44; in order to improve the perception of the general population on the effectiveness of influenza vaccination&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Involve patient associations and associations for the elderly in spreading information and improving vaccination coverage&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Use all the information that appears in Spanish scientific societies and by authors in our environment that encourages the spread of vaccination&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Establish strategies that enable coverage to be measured in groups with special clinical conditions at high risk of complications and take advantage of any contact with the health system to recommend vaccination&#46;</p></li></ul></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0220" class="elsevierStylePara elsevierViewall">Influenza is an immune preventable disease that affects all population groups&#46; It has major social and economic impact&#44; although in most cases it is mild&#44; it can have serious complications that require hospitalisation and can even cause death&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Influenza vaccination is the most effective form of preventing the disease and its complications&#44; significantly reducing the number of hospitalisations and deaths&#44; especially among the most vulnerable&#44; such as the elderly and other groups with risk factors&#46; We now have increasingly safer and more effective vaccines&#46; In addition to the usual trivalent vaccines or adjuvant vaccines&#44; in recent years tetravalent vaccines have been developed that increase the level of protection without modifying the safety or immunogenicity profile&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">32&#8211;34</span></a> In general&#44; there is poor perception of the risk of infection by the influenza virus and the severity of the disease&#44; and there is a lack of precise information on the effectiveness of the vaccines&#44; particularly among health personnel&#46; It is necessary and urgent to raise the awareness and involve this group of professionals&#44; as well as pharmacists &#40;as information agents&#41;&#44; so that they become vaccinated and recommend the vaccination&#46; Similarly&#44; it is important to optimise the participation of the media and explore and exploit the potential of the new technologies in conveying true information to the entire population&#46; The scientific societies and associations for patients and the elderly can play an important role and their participation in training and conveying information should be encouraged&#46; Access to influenza vaccination must be facilitated&#44; and its benefits communicated&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of interest</span><p id="par0230" class="elsevierStylePara elsevierViewall">The medical writing support for this document was financed through a non-restricted contribution given by Sanofi-Aventis S&#46;A&#46; In activities unrelated to this paper&#44; the authors declare that they have received financing or non-financial support from various companies&#58; AG&#44; from Pfizer&#44; Sanofi-Pasteur and MSD&#59; MFP&#44; from Pfizer&#44; Glaxo Smith Kline&#44; Sanofi-Pasteur and Pfizer&#59; JA&#44; from Sanofi-Pasteur&#59; DM&#44; from Glaxo Smith Kline and Sanofi-Pasteur&#59; ER&#44; from Glaxo Smith Kline&#44; Sanofi-Pasteur&#44; Pfizer&#44; Novartis and MSD&#59; IJ&#44; from Pfizer&#59; MGC&#44; from Sanofi-Pasteur&#44; Glaxo Smith Kline&#44; Pfizer and MSD&#59; JALP&#44; from Sanofi-Pasteur and Pfizer&#46;</p></span></span>"
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              "titulo" => "People with chronic diseases and immunodepressed people"
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              "titulo" => "Pregnant women"
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              "titulo" => "Other groups that should be vaccinated"
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                  "titulo" => "People who live with people with high-risk diseases"
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          "titulo" => "Recommendations for influenza vaccination in Spain"
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          "titulo" => "Strategies to increase vaccination coverage"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Influenza is the most common infectious disease preventable by vaccination in developed countries&#59; it can affect people of all ages and cause epidemics&#46; Although the symptoms are usually mild&#44; complications may arise that require a hospital admission and might cause the patient&#39;s death in some cases&#46; Vaccination is the most effective way to prevent influenza&#44; and the World Health Organization recommends reaching immunization coverages against influenza of at least 75&#37; in people over 65 years of age and in the high-risk population&#44; as well as among healthcare professionals&#46; This document summarizes the key points of a recent document containing information updates and considerations regarding influenza vaccination in Spain and the present recommendations&#46; The document was issued by the Influenza Study Group and the signing scientific societies and professional organizations&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La gripe es la enfermedad infecciosa&#44; prevenible mediante vacunaci&#243;n&#44; m&#225;s frecuente en los pa&#237;ses desarrollados&#44; y puede afectar a personas de todas las edades y dar lugar a epidemias&#46; Aunque la sintomatolog&#237;a habitualmente es leve&#44; pueden aparecer complicaciones que requieran ingreso hospitalario y causar en algunos casos la muerte del paciente&#46; La vacunaci&#243;n es la forma m&#225;s efectiva de prevenirla y la Organizaci&#243;n Mundial de la Salud recomienda alcanzar una cobertura vacunal frente a la gripe de al menos el 75&#37; en personas mayores de 65 a&#241;os y en la poblaci&#243;n de alto riesgo&#44; as&#237; como en los profesionales sanitarios&#46; Este documento resume los puntos fundamentales de un trabajo de actualizaci&#243;n y reflexi&#243;n sobre la vacunaci&#243;n antigripal en Espa&#241;a y las recomendaciones al respecto&#44; que realizaron el Grupo de Estudio de la Gripe y las sociedades cient&#237;ficas y organizaciones profesionales firmantes&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Please cite this article as&#58; Garc&#237;a A&#44; Fern&#225;ndez-Prada M&#44; Aristegui J&#44; Moreno D&#44; Redondo E&#44; Jimeno I&#44; et al&#46; Resumen ejecutivo del documento de actualizaci&#243;n y reflexi&#243;n sobre vacunaci&#243;n antigripal en Espa&#241;a&#46; Vacunas&#46; 2018&#59;19&#58;85&#8211;98&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0040">This document is the executive summary of the <span class="elsevierStyleItalic">Executive summary of the update and reflection document on influenza vaccination in Spain</span>&#44; endorsed by the Spanish Vaccinology Association &#40;AEV&#41;&#44; Spanish Paediatric Association &#40;AEP&#41;&#44; Spanish Society of Primary Care Physicians &#40;SEMERGEN&#41;&#44; Spanish Society of General and Family Physicians &#40;SEMG&#41;&#44; Spanish Society of Preventive Medicine&#44; Public Health and Hygiene &#40;SEMPSPH&#41; and the Spanish Society of Geriatrics and Gerontology &#40;SEGG&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Adapted from Ortiz de Lejarazu and Tamames&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">7</span></a></p>"
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="7" align="left" valign="top">Inactivated</td><td class="td" title="table-entry  " align="left" valign="top">Complete viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More reactogenic&#44; some adverse reactions<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">20&#44;31</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8730;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Viral subunits &#40;HA and NA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highly purified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adjuvanted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Greater antigenic response or protection spectrum<br>Important role in immunising people over the age of 65<a class="elsevierStyleCrossRefs" href="#bib0980"><span class="elsevierStyleSup">72&#8211;74</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Greater antigenic response or protection spectrum<br>Simulate the structure and arrangement of the whole virion<a class="elsevierStyleCrossRefs" href="#bib0995"><span class="elsevierStyleSup">75&#44;76</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intradermal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enter into direct contact with the Langerhans cells and the dendritic skin cells&#44; which results in greater immunogenicity<a class="elsevierStyleCrossRef" href="#bib1005"><span class="elsevierStyleSup">77</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8730;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Greater antigenic response&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Season&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Most prevalent B strain lineage in Spain&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2007&#8211;2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Solomon Islands&#47;3&#47;2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Wisconsin&#47;67&#47;2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">B&#47;Malaysia&#47;2506&#47;2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yamagata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#9679;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2008&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Brisbane&#47;59&#47;2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Brisbane&#47;10&#47;2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">B&#47;Florida&#47;4&#47;2006</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Victoria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#9679;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2009&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Brisbane&#47;59&#47;2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Brisbane&#47;10&#47;2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">B&#47;Brisbane&#47;60&#47;2008</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Victoria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">20010&#8211;2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;California&#47;7&#47;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Perth&#47;16&#47;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">B&#47;Brisbane&#47;60&#47;2008</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Victoria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2011&#8211;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;California&#47;7&#47;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Perth&#47;16&#47;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">B&#47;Brisbane&#47;60&#47;2008</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yamagata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#9679;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2012&#8211;2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;California&#47;7&#47;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Victoria&#47;361&#47;2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">B&#47;Wisconsin&#47;1&#47;2010</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yamagata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2013&#8211;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Christchurch&#47;16&#47;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Texas&#47;50&#47;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">B&#47;Brisbane&#47;33&#47;2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">B&#47;Massachusetts&#47;2&#47;2012</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yamagata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#9679;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2014&#8211;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;California&#47;7&#47;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Texas&#47;50&#47;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">B&#47;Brisbane&#47;60&#47;2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">B&#47;Massachusetts&#47;2&#47;2012</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yamagata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2015&#8211;2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;California&#47;7&#47;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Switzerland&#47;9715293&#47;2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">B&#47;Brisbane&#47;60&#47;2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">B&#47;Phuket&#47;3073&#47;2013</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Victoria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#9679;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2016&#8211;2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;California&#47;7&#47;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Hong Kong&#47;4801&#47;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">B&#47;Brisbane&#47;60&#47;2008</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">B&#47;Phuket&#47;3073&#47;2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Victoria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2017&#8211;2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Michigan&#47;45&#47;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#47;Hong Kong&#47;4801&#47;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">B&#47;Brisbane&#47;60&#47;2008</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">B&#47;Phuket&#47;3073&#47;2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yamagata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#9679;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">In this 2013&#8211;2014 season Yamagata and Victoria co-circulated&#44; therefore there was partial mismatch&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">Source&#58; Table constructed with the data from the WHO annual recommendations&#44;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">48</span></a> data from the reports of season ISCIII&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">24</span></a></p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Composition recommended by the WHO for the trivalent and tetravalent influenza vaccines over the past 10 seasons and predominant B strain&#47;lineage in Spain during that season&#46;</p>"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">PF&#58; pharmaceutical form&#59; I&#58; intranasal&#59; ID&#58; intradermal delivery&#59; IM&#58; intramuscular&#59; PS&#58; preloaded syringe&#59; S&#58; suspension&#59; IS&#58; injectable suspension&#59; DSI&#58; deep subcutaneous injection&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Source&#58; CIMA&#46;<a class="elsevierStyleCrossRef" href="#bib1025"><span class="elsevierStyleSup">81</span></a></p>"
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                  <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="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Name&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PF&#47;presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Laboratory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Immunogen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Route&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afluria<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IS&#47;PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Seqirus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trivalent&#47;split&#47;inactivated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IM&#47;DSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chiroflu<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IS&#47;PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Seqirus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trivalent&#47;surface antigen&#47;inactivated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IM&#47;DSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chiromas<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IS&#47;PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Seqirus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trivalent&#47;surface antigen&#47;inactivated&#47;adjuvant MF59C&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;65 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Influvac<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IS&#47;PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mylan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trivalent&#47;surface antigen&#47;inactivated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IM&#47;DSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intanza<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IS&#47;PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sanofi Pasteur Europe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trivalent&#47;split&#47;inactivated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;60 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ID&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mutagrip<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IS&#47;PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sanofi Pasteur Europe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trivalent&#47;split&#47;inactivated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IM&#47;DSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaxigrip<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IS&#47;PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sanofi Pasteur Europe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trivalent&#47;split&#47;inactivated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IM&#47;DSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluarix Tetra<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IS&#47;PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GlaxoSmithKline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tetravalent&#47;split&#47;inactivated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaxigrip Tetra<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IS&#47;PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sanofi Pasteur Europe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tetravalent&#47;split&#47;inactivated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IM&#47;DSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluenz Tetra<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#47;I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Astra Zeneca&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tetravalent&#47;whole virions&#47;attenuated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 to 18 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Authorised influenza vaccines in Spain&#46;</p>"
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        "etiqueta" => "Table 4"
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          "tablatextoimagen" => array:1 [
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              "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="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Contraindication&#47;precaution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Temporary situations</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pregnancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Live-attenuated vaccines should not be used&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Immunodepression or immunosuppression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Live attenuated vaccines should not be used &#40;injected or intranasal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Any moderate or severe disease<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> with or without fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No vaccination should be given in general&#44; except in situations of extremely high epidemic risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Under the age of 18 and treated with salicylates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intranasal live-attenuated vaccine should not be used<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Under the age of 18 with severe asthma or active wheezing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intranasal live-attenuated vaccine should not be used<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Under the age of 6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Influenza vaccine should not be given&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Precautions</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">There should be no vaccination in general&#44; until it subsides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>History of Guillain-Barr&#233; syndrome in the 6 months after administration of a vaccine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Carefully assess whether or not it is appropriate to give a dose after this vaccine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intranasal<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a> administration of live-attenuated agents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoid contact with severely immunodepressed people for 1&#46;2 weeks after vaccination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">For example&#44; asthma attack&#44; decompensated heart disease&#44; acute diarrhoea&#44; etc&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Authorised&#44; but not marketed in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib1030"><span class="elsevierStyleSup">82</span></a></p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Temporary contraindications and precautions with the influenza vaccination&#46;</p>"
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      4 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">COPD&#58; chronic obstructive pulmonary disease&#59; HIV&#58; human immunodeficiency virus&#46;</p>"
          "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="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Population group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Notes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Immunodepressed people</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Primary immunodepression &#40;hereditary or genetic disorders&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Immunodepression in general is an important risk factor for contracting flu and developing complications<a class="elsevierStyleCrossRefs" href="#bib1035"><span class="elsevierStyleSup">83&#44;84</span></a><br>The attenuated vaccines are completely contraindicated in the case of severe immunodepression&#46; Inactivated vaccines should be used<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">56</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Secondary immunodepression &#40;disease acquired or drug-induced immunodeficiency&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Immunodepression in general is an important risk factor for contracting flu and developing complications<a class="elsevierStyleCrossRefs" href="#bib1035"><span class="elsevierStyleSup">83&#44;84</span></a><br>The influenza vaccines are effective for HIV-infected people&#44; although the benefit is reduced in the case of advanced disease<a class="elsevierStyleCrossRefs" href="#bib1045"><span class="elsevierStyleSup">85&#44;86</span></a><br>The attenuated vaccines are completely contraindicated in the case of severe immunodepression&#46; Inactivated vaccines should be used<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">56</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Chronic diseases</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rheumatic diseases &#40;whether or not treated with immunosuppressants and&#47;or disease modifying drugs&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients with rheumatoid arthritis suffer a greater burden of infectious disease-related morbidity and mortality and have double the risk of contracting a severe infection than that of the general population&#46; This is associated with autoimmune disease as well as the immunosuppressive therapies that are commonly used for this population<a class="elsevierStyleCrossRef" href="#bib1055"><span class="elsevierStyleSup">87</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cystic fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is particularly important to avoid diseases that cause lung deterioration such as influenza or pneumonia<a class="elsevierStyleCrossRef" href="#bib1060"><span class="elsevierStyleSup">88</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic cardiovascular diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Carry a high risk of complications&#44; hospitalisation and death due to the flu virus<a class="elsevierStyleCrossRefs" href="#bib1065"><span class="elsevierStyleSup">89&#8211;91</span></a><br><span class="elsevierStyleHsp" style=""></span>Inflammatory response and viral infection induce the production of autoantibodies against low density lipoproteins&#44; causing the development and progression of atherosclerotic vascular lesions<br><span class="elsevierStyleHsp" style=""></span>Direct colonisation of the vessel wall starts local autoimmune reactions&#44; by the activation of antigen-presenting cells<br>Vaccination has a major protective effect in patients with prior heart disease&#44; especially acute myocardial infarction&#44; reducing the mortality rate due to influenza by &#62;60&#37;<a class="elsevierStyleCrossRef" href="#bib1070"><span class="elsevierStyleSup">90</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic neurological and neuromuscular diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increase the risk of complications due to disorders that compromise normal lung function and secretory capacity<a class="elsevierStyleCrossRefs" href="#bib1080"><span class="elsevierStyleSup">92&#44;93</span></a><br><span class="elsevierStyleHsp" style=""></span>Due to reduced muscle power for inspiration and expiration<br><span class="elsevierStyleHsp" style=""></span>Reduced muscle tone&#44; reduced mobility<br><span class="elsevierStyleHsp" style=""></span>Structural physical conditions&#44; such as scoliosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic lung disease &#40;COPD&#44; asthma&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Most COPD exacerbations are caused by respiratory infections&#44; although there are other factors<a class="elsevierStyleCrossRef" href="#bib1090"><span class="elsevierStyleSup">94</span></a><br>Influenza is more common and has more complications in patients with acute respiratory disorders such as COPD and asthma&#46;<a class="elsevierStyleCrossRefs" href="#bib1095"><span class="elsevierStyleSup">95&#44;96</span></a> The influenza vaccine is effective in this group and its effects are even greater when given to elderly people&#46;<a class="elsevierStyleCrossRefs" href="#bib1090"><span class="elsevierStyleSup">94&#44;97&#8211;99</span></a> Various organisations recommend vaccination for this group<a class="elsevierStyleCrossRefs" href="#bib0740"><span class="elsevierStyleSup">24&#44;56&#44;58&#8211;61</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Metabolic diseases &#40;including diabetes mellitus&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hyperglycaemia in diabetic patients weakens the immune system&#44; increasing susceptibility to infections&#44; while these in turn can increase glycaemia<a class="elsevierStyleCrossRefs" href="#bib1120"><span class="elsevierStyleSup">100&#44;101</span></a><br>The vaccine reduces the complications as well as the mortality associated with the disease<a class="elsevierStyleCrossRefs" href="#bib0855"><span class="elsevierStyleSup">47&#44;102&#8211;107</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Morbid obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">This group has a higher rate of admissions than the normal population and poorer disease outcome&#46;<a class="elsevierStyleCrossRef" href="#bib1160"><span class="elsevierStyleSup">108</span></a> The international guidelines include morbid obesity on the list of vaccination recommendations<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">51&#44;56&#44;58&#44;60&#44;61&#44;109&#44;110</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic kidney failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Is usually associated with a degree of immunosuppression&#44; comorbidities such as hypertension or diabetes&#44; and common in advanced age<br>Since 2015&#44; stage 3b &#40;of 5&#41; patients have been expressly included&#44; with a glomerular filtration rate of 30&#8211;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span><a class="elsevierStyleCrossRef" href="#bib1175"><span class="elsevierStyleSup">111</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anaemia and haemoglobinopathies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Influenza &#40;especially caused by the H1N1 virus&#41; is often severe in this case&#44; mainly among the elderly&#44;<a class="elsevierStyleCrossRef" href="#bib1180"><span class="elsevierStyleSup">112</span></a> and carries an increased risk of hospitalisation<a class="elsevierStyleCrossRef" href="#bib1185"><span class="elsevierStyleSup">113</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asplenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Various studies demonstrate that the influenza vaccine can reduce the risk of death by 54&#37; in asplenic patients<a class="elsevierStyleCrossRefs" href="#bib1040"><span class="elsevierStyleSup">84&#44;114&#44;115</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic liver disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Influenza can be a cause of liver decompensation in cirrhosis patients&#46;<a class="elsevierStyleCrossRefs" href="#bib1040"><span class="elsevierStyleSup">84&#44;116</span></a> Annual vaccination as a principal strategy to reduce the complications and mortality caused by influenza<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">56&#44;58&#8211;61&#44;117</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vaccination is especially recommended for certain types of cancer that affect the bone marrow&#44; such as leukaemias&#44; multiple myeloma or lymphoma&#46; The immunosuppression caused by antitumour treatments should also be considered&#46;<a class="elsevierStyleCrossRef" href="#bib1210"><span class="elsevierStyleSup">118</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Down&#39;s syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Immunological anomalies are common in the humoral and cellular compartments and there is high morbidity and mortality due to infectious diseases&#44; especially of the respiratory tract and particularly in the first 5 years of life&#44; and at more advanced ages&#46; <a class="elsevierStyleCrossRefs" href="#bib1215"><span class="elsevierStyleSup">119&#44;120</span></a> Influenza vaccination is strongly recommended<a class="elsevierStyleCrossRefs" href="#bib1225"><span class="elsevierStyleSup">121&#44;122</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Other</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cochlear implantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Implanted patients are at more risk of severe infections&#44; such as meningitis and otitis media&#44; which can be secondary to infection with the influenza virus<a class="elsevierStyleCrossRefs" href="#bib1040"><span class="elsevierStyleSup">84&#44;123&#44;124</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Paediatric patients under treatment with salicylates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Annual influenza vaccination is recommended from the age of 6 months&#44; to reduce the risk of Reye&#39;s syndrome&#46; Intranasal attenuated vaccine should not be given &#40;not marketed in Spain&#41;&#46; Moreover&#44; allow 4 weeks before starting treatment with salicylates in paediatric patients vaccinated with live viruses<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">50</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Chronic diseases and immunodepression disorders where influenza vaccination is recommended&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">HIV&#58; human immunodeficiency virus&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1&#46; People over the age of 65&#46; Especially if living together in institutions</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2&#46; People under the age of 65 at high risk of influenza-related complications</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2&#46;1&#46; Children &#40;over the age of 6 months&#41; and adults with chronic cardiovascular disease &#40;excluding isolated arterial hypertension&#41;&#44; neurological or lung disease&#44; including bronchopulmonary dysplasia&#44; cystic fibrosis and asthma&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2&#46;2&#46; Children &#40;over the age of 6 months&#41; and adults with&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Metabolic diseases&#44; including diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Morbid obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Kidney failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Haemoglobinopathies and anaemias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Asplenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Chronic liver disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Severe neuromuscular diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Immunosuppression &#40;including due to HIV or drugs&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Rheumatic diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cochlear implant or awaiting implantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Disorders and diseases that involve cognitive dysfunction&#58; Down&#39;s syndrome&#44; dementia and others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2&#46;3&#46; Children and adolescents&#44; from 6 months to 18 years&#44; receiving prolonged treatment with acetylsalicylic acid&#44; due to the possibility of developing Reye&#39;s syndrome after influenza</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2&#46;4&#46; Women in any trimester of pregnancy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3&#46; People who might transmit influenza to others with a risk of complications&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3&#46;1&#46; Workers in health centres&#44; services and establishments&#46; Particularly health professionals caring for patients in the high risk groups of point 2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3&#46;2&#46; People working in geriatric institutions or care centres for chronically ill patients</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3&#46;3&#46; Work placement students in healthcare centres</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3&#46;4&#46; People who provided domiciliary care for patients at high risk or the elderly</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3&#46;5&#46; People over the age of 6 months living in the same home as others from any of the high risk groups of point 2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">4&#46; Other groups for whom vaccination is recommended&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4&#46;1&#46; People working in the essential public services&#46; Particularly&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>The national&#44; regional or local law-enforcement and security agencies of the State&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Fire fighters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Civil protection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Health emergency services&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Penal institutions and other related detention facilities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">4&#46;2&#46; Workers who are directly exposed to poultry or pigs in farms or poultry or pig farming industries&#44; and wild birds</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Special emphasis will be placed in this group on those requiring periodic medical follow-up or who have been hospitalised in the preceding year&#46; Those under the age of 65 who live together in institutions should also be considered&#46;</p> <p class="elsevierStyleNotepara" id="npar0030">Source&#58; Ministry of Health&#44; Consumption and Social Welfare&#46;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">56</span></a></p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Current vaccination recommendations in Spain&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:124 [
            0 => array:3 [
              "identificador" => "bib0625"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Organizaci&#243;n Mundial de la Salud&#46; Centro de prensa&#46; Gripe &#40;estacional&#41; &#91;Internet&#93;&#59; 2016&#46; Available from&#58; <a id="intr0010" class="elsevierStyleInterRef" href="http://www.who.int/mediacentre/factsheets/fs211/es/">http&#58;&#47;&#47;www&#46;who&#46;int&#47;mediacentre&#47;factsheets&#47;fs211&#47;es&#47;</a> &#91;accessed Jul 2018&#93;&#46;"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0630"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Ministerio de Sanidad&#44; Consumo y Bienestar Social&#46; Sanidad&#46; Ciudadanos&#46; Enfermedades&#46; Enfermedades transmisibles&#46; Gripe &#91;Internet&#93;&#46; Available from&#58; <a id="intr0015" class="elsevierStyleInterRef" href="http://www.mscbs.gob.es/ciudadanos/enfLesiones/enfTransmisibles/gripe/home.htm">http&#58;&#47;&#47;www&#46;mscbs&#46;gob&#46;es&#47;ciudadanos&#47;enfLesiones&#47;enfTransmisibles&#47;gripe&#47;home&#46;htm</a> &#91;accessed July 2018&#93;&#46;"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0635"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <a class="elsevierStyleInterRef" target="_blank" id="intr0020" href="http://www.vacunas.org/documento-de-actualizacion-y-reflexion-sobre-la-vacunacion-antigripal-en-espana/">http&#58;&#47;&#47;www&#46;vacunas&#46;org&#47;documento-de-actualizacion-y-reflexion-sobre-la-vacunacion-antigripal-en-espana&#47;</a> &#91;accessed Sep 2018&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Documento de actualizaci&#243;n y reflexi&#243;n sobre vacunaci&#243;n antigripal en Espa&#241;a &#91;Internet&#93;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2018"
                        "editorial" => "Esmon"
                        "editorialLocalizacion" => "Barcelona"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0640"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "World Health Organization&#46; Methods for assessing influenza vaccination coverage in target groups &#91;Internet&#93;&#59; 2016&#46; Available from&#58; <a id="intr0025" class="elsevierStyleInterRef" href="http://www.euro.who.int/__data/assets/pdf_file/0004/317344/Methods-assessing-influenza-vaccination-coverage-target-groups.pdf?ua=1">http&#58;&#47;&#47;www&#46;euro&#46;who&#46;int&#47;&#95;&#95;data&#47;assets&#47;pdf&#95;file&#47;0004&#47;317344&#47;Methods-assessing-influenza-vaccination-coverage-target-groups&#46;pdf&#63;ua&#61;1</a> &#91;accessed Ene 2018&#93;&#46;"
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0645"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Influenza D virus in cattle&#44; France&#44; 2011&#8211;2014"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3201/eid2102.141449"
                      "Revista" => array:6 [
                        "tituloSerie" => "Emerg Infect Dis"
                        "fecha" => "2015"
                        "volumen" => "21"
                        "paginaInicial" => "368"
                        "paginaFinal" => "371"
                        "link" => array:1 [ …1]
                      ]
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                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0650"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "European Centre for Disease Prevention and Control &#40;ECDC&#41;&#46; Factsheet about seasonal influenza &#91;Internet&#93;&#46; Available from&#58; <a id="intr0030" class="elsevierStyleInterRef" href="https://ecdc.europa.eu/en/seasonal-influenza/facts/factsheet">https&#58;&#47;&#47;ecdc&#46;europa&#46;eu&#47;en&#47;seasonal-influenza&#47;facts&#47;factsheet</a> &#91;accessed July 2018&#93;&#46;"
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0655"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "&#91;in Spanish&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Influenza vaccination&#46; Effectiveness of current vaccines and future challenges&#93;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
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Article information

ISSN: 24451460
Original language: English

DOI:10.1016/j.vacune.2018.10.001

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