SEPAR recommendations and new challenges on COVID-19 vaccine in respiratory diseases

de la Rosa-Carrillo, D.; López-Campos, J.L.; Blanco Aparicio, M.; Villar-Álvarez, F.
doi:10.1016/j.vacune.2021.10.001
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The scientific community realised that mass vaccination of the population was the best tool to combat SARS-CoV-2 from the moment it was declared a pandemic&#46; After a great effort&#44; several vaccines were developed in less than a year&#44; some using very new technology&#46; Given their limited availability&#44; the Council of the Spanish National Health System proposed from the outset a vaccination strategy based on the age and risk of the population&#44; aimed primarily at reducing mortality&#44; transmissibility&#44; and the burden on essential services&#46; Priority was given to vaccinating nursing homes&#44; healthcare workers&#44; essential service workers&#44; and people with severe disabilities&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This strategy has been adjusted to the availability of vaccines&#44; progressively prioritising patients with oncohaematological diseases&#44; immunosuppression&#44; or dialysis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However&#44; patients at high-risk for an unfavourable outcome&#44; with chronic respiratory diseases&#44; cardiovascular diseases or obesity&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> for example&#44; are left for later stages&#46; Moreover&#44; the onset of various side effects has generated the need to identify risks and contraindications of this vaccination&#44; especially in the most vulnerable patients&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Therefore&#44; the Spanish Society of Pneumology and Thoracic Surgery &#40;SEPAR&#41; has drawn up a document to help healthcare personnel in vaccinating patients with respiratory diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Experts in pulmonology&#44; thoracic surgery&#44; nursing&#44; microbiology&#44; immunology&#44; preventive medicine&#44; epidemiology&#44; and public health participated&#46; A literature review was conducted for the three compounds that had been approved at that time&#58; Pfizer&#47;BioNTech&#44; Moderna and AstraZeneca&#46; The document reviews their main characteristics&#44; analyses the global vaccination strategy proposed by the Ministry of Health and emphasises the important role of pulmonologists in achieving good adherence and vaccination coverage in patients with respiratory diseases&#46; Finally&#44; we give a series of recommendations for the management of the COVID-19 vaccine in different respiratory and thoracic diseases&#44; acute and chronic&#44; that make the patient especially vulnerable to SARS-CoV-2 infection &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The paper concludes that COVID-19 vaccines are not only safe and effective&#44; but are even a priority in vulnerable patients with chronic respiratory diseases&#46; We are therefore left with the challenge of immunising this large population&#44; as the availability of the vaccines is still limited&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The efficacy of vaccines against new strains of the virus is another area of uncertainty&#46; RNA viruses&#44; such as SARS-CoV-2&#44; tend to mutate in successive replication cycles due to errors in RNA-copying enzymes&#46; Although this may suggest a threat to vaccine effectiveness&#44; its impact on vaccine efficacy must be put into context&#46; First&#44; although some strains appear to be more infectious because they have a higher viral load in the upper respiratory tract&#44; they do not always result in more severe infection&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Some authors argue that the mutated strains currently circulating have not had a major impact on the course of the pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Secondly&#44; vaccines generate an immune response usually involving a wide range of antibodies&#44; and preclinical models have shown that mRNA vaccines produce antibodies that block the mutated viruses better than the original viruses&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Growing concerns about the potential transmissibility&#44; virulence and ability of new variants to undermine the efficacy of existing vaccines<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> are an argument in favour of accelerating mass vaccination of the population&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The obstacles to achieving this goal range from denialism&#44; vaccine shortages&#44; onset of side effects with continuous interruptions of administration&#44; storage requirements or uncertainty about the duration of immunity&#46; Vaccine shortages generated debate about prioritising a single dose to more people or even spacing doses&#46; It should be noted that mRNA vaccines can become dose-dependent&#44; requiring the integration of genetic information into the immunity cells&#46; Removing patents to increase production is an unresolved debate&#44; although the production of preparations with exactly the same formulation and quality in all batches should be ensured&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Reports of serious cases of thrombosis associated with certain vaccines<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> raised questions about their use in patients with conventional risk factors for thrombosis&#46; However&#44; as they act by an immune mechanism&#44; no restrictions are envisaged in this regard&#46; Nor is it currently possible to determine the risk factors for this adverse reaction&#44; although because of their similar pathogenesis they are not recommended in people with a history of heparin-induced thrombocytopenia&#46; There is a question as to the efficacy&#44; efficiency&#44; and safety of combining vaccines with different mechanisms of action&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As we wait for science to resolve all the uncertainties surrounding the COVID-19 vaccine&#44; new challenges are emerging&#44; including whether global vaccination will be sufficient to eradicate this unexpected pandemic&#44; or whether we will have to live with the virus forever&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; de la Rosa-Carrillo D&#44; L&#243;pez-Campos JL&#44; Blanco Aparicio M&#44; Villar-&#193;lvarez F&#46; Recomendaciones SEPAR y nuevos retos sobre la vacuna contra la COVID-19 en las enfermedades respiratorias&#46; Vacunas&#46; 2021&#59;22&#58;131&#8211;134&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Respiratory disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Previous SARS-CoV-2 infection&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Patients with a history of confirmed previous SARS-CoV-2 infection should be vaccinated according to the current recommendation&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Vaccination in previously infected patients could be delayed for six months and be done in a single dose&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Warn about a potentially intense post-vaccination reaction in subjects infected less than six months earlier&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Current respiratory infection&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Vaccination should be postponed in people with severe acute febrile illness &#40;&#8805;38&#8239;&#176;C&#41; or acute infection&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">The presence of mild infection and&#47;or low-grade fever should not postpone vaccination&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Severe asthma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Administration of the SARS-CoV-2 vaccine is advised in patients with allergic asthma with sensitisation to inhaled allergens &#40;dust mites&#44; pollens&#44; animal epithelia&#44; fungi&#41;&#44; as there is no evidence to the contrary&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with severe asthma treated with biological drugs can receive the SARS-CoV-2 vaccine&#44; but it is advisable to delay administration of the biological agent for 5&#8722;7 days&#44; essentially as surveillance for possible adverse effects after vaccination&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with severe asthma treated with biological agents could be a priority group for the vaccine&#44; as recent studies have observed worse COVID-19 disease progression in this subgroup&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The SARS-COV-2 vaccine should not be administered to patients with a history of anaphylactic reaction to biological drugs&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stable and acute COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with COPD should be a priority group for vaccination against SARS-CoV-2&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with Alpha-1-antitrypsin deficiency &#40;AATD&#41; should be a priority group for vaccination against SARS-CoV-2&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neither smoking&#44; COPD treatment nor replacement therapy for AAD is a contraindication for vaccination against SARS-CoV-2&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It seems common sense not to recommend vaccination during flare-ups&#44; regardless of the severity of the flare-up&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bronchiectasis and chronic bronchial infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with bronchiectasis with&#47;without chronic bronchial infection should be vaccinated against SARS-CoV-2&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Preventive antibiotic&#44; steroid or other treatment prior to vaccination is not necessary&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Any basic treatment regimen should not be changed because of vaccination&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">During a flare-up&#44; it is reasonable to wait for the process to stabilise before proceeding with vaccination&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pulmonary hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vaccination against COVID-19 is recommended in patients with pulmonary hypertension&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It is recommended that COVID-19 vaccination should not be administered during episodes of decompensation of pulmonary hypertension&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with pulmonary hypertension receiving anticoagulant therapy should not discontinue anticoagulant therapy&#44; but should take precautions&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pulmonary thromboembolism and anticoagulant therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anticoagulant therapy does not contraindicate vaccination against COVID-19&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It is recommended not to administer COVID-19 vaccine in the acute phase of pulmonary thromboembolism&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cancer under active treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vaccination is recommended in patients with advanced cancer&#44; especially those diagnosed with lung cancer under active treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">There are no data to support patients with a history of cancer being prioritised for vaccination&#46; Other risk factors should be considered&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">There is no contraindication to vaccination while undergoing cancer treatment&#44; but vaccination is recommended before starting treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DILD and anti-fibrotic or immunosuppressive therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with diffuse interstitial lung disease &#40;DILD&#41;&#44; especially those with fibrosing DILD&#44; are at high risk for severe infection and should be prioritised for vaccination against SARS-CoV-2&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">There is no evidence of interaction with antifibrotic medication&#44; and therefore the usual treatment regimens should not be modified&#44; either before or after vaccination against SARS-CoV-2&#44; as is the case with influenza or pneumococcal vaccination in these patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">During a flare of DILD&#44; it is reasonable to wait for the process to stabilise before proceeding with SARS-CoV-2 vaccination&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients with DILD associated with systemic autoimmune diseases and immunomodulatory treatment&#44; vaccination against SARS-CoV-2 is recommended&#44; with attention to patients on treatment with B-cell depleting antibodies&#44; preferably administered before planned immunosuppression or away from the infusion&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lung transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vaccination against COVID-19 is recommended in lung transplant recipients and candidates on the waiting list&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vaccination should be performed at a time when the underlying disease is stable&#44; and baseline immunosuppressive treatment regimens do not need to be modified&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chest surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emergency surgeries should take place regardless of vaccination status&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It is recommended to schedule the vaccination process and the elective surgical procedure so that neither are delayed&#44; separating them by a maximum of one week&#44; respecting the dose intervals and individualising them in the case of immunodeficiencies&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2794048.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Main recommendations on the use of the COVID-19 vaccine&#44; according to respiratory disease&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:10 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Grupo de Trabajo T&#233;cnico de Vacunaci&#243;n COVID-19 de la Ponencia de Programa y Registro de Vacunaciones&#46; Estrategia de Vacunaci&#243;n frente a COVID-19 en Espa&#241;a&#46; Consejo Interterritorial del SNS&#47;Ministerio de Sanidad&#46; 2 December 2020 &#91;accessed 26 Apr 2021&#93;&#46; Available from&#58; <a target="_blank" href="https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID19_EstrategiaVacunacion.pdf">https&#58;&#47;&#47;www&#46;mscbs&#46;gob&#46;es&#47;profesionales&#47;saludPublica&#47;prevPromocion&#47;vacunaciones&#47;covid19&#47;docs&#47;COVID19&#95;EstrategiaVacunacion&#46;pdf</a>&#46;"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Grupo de Trabajo T&#233;cnico de Vacunaci&#243;n COVID-19 de la Ponencia de Programa y Registro de Vacunaciones&#46; Actualizaci&#243;n 5&#46; Estrategia de vacunaci&#243;n frente a COVID-19 en Espa&#241;a&#46; 30 March 2021 &#91;accessed 26 Apr 2021&#93;&#46; <a target="_blank" href="https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion5_EstrategiaVacunacion.pdf">https&#58;&#47;&#47;www&#46;mscbs&#46;gob&#46;es&#47;profesionales&#47;saludPublica&#47;prevPromocion&#47;vacunaciones&#47;covid19&#47;docs&#47;COVID-19&#95;Actualizacion5&#95;EstrategiaVacunacion&#46;pdf</a>&#46;"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of underlying diseases in died cases of COVID-19&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "F&#46; Javanmardi"
                            1 => "A&#46; Keshavarzi"
                            2 => "A&#46; Akbari"
                            3 => "A&#46; Emami"
                            4 => "N&#46; Pirbonyeh"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0244157"
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