ABSTRACT Introduction: Influenza is a global threat, with high epidemic potential and affects between 5 and 15% of the world's population annually. In the hospital environment, vaccination is crucial to protect healthcare professionals. However, despite international recommendations, vaccination uptake is low due to safety concerns and/or distrust. Studies show that vaccinated professionals have lower rates of absenteeism, and when infected with the virus, they present milder symptoms. In this work, a retrospective cross-sectional observational study is carried out on the vaccination rate against this disease in a population of hospital-based workers, from 2019 to 2023. To understand the importance of vaccination against Influenza in these workers and which behavioral determinants may justify considering this evolution, we carried out a review of the challenges of vaccination among health professionals and identified key points to develop strategies with the aim of promoting adherence to vaccination campaigns. Methodology: For the observational study, vaccination data from hospital health professionals by the Occupational Health Service was used, recorded on a specific form at the time of administration. Professional category was the only variable considered. Data analysis was performed using Microsoft® Excel®. For the review, the databases Medline, Science Direct and Google Scholar were used, with the keywords "Influenza vaccine”, “health professional” and “behaviour”, selecting studies from 2010 to 2024. From the result of 1277 works, the exclusion criteria, which included vaccination for other diseases and target populations that did not include health professionals, 22 bibliographic sources were selected. To reflect the national reality, articles on the topic published by the Revista Portuguesa de Saúde Ocupacional Online were included, as well as complementary studies and reference documents. Results: The study of adherence to flu vaccination in this hospital peripheral to Lisbon, between 2019 and 2023, showed a variation in vaccination adherence, with an average of 30%, a value below the ones reported in other countries. The categories most hesitant about this vaccine were Nursing Staff and Technical Assistants; at the opposite extreme, there was greater adherence from Medical Personnel and Technical Assistants. During the COVID-19 Pandemic, an increasing number of professionals were vaccinated annually, with this trend reversing after the end of the global emergency of this disease. From the review of the literature on vaccine hesitancy, 8 of the 14 behavioral domains stand out that represent theories of behavioral change that constitute modifiable factors that influence behavior in relation to the vaccine. We approach each of them from this perspective, namely: knowledge, the environmental context and resources, social influence, beliefs and knowledge about consequences, beliefs about individual capacity, identity and social/professional role, reinforcement and emotion. Discussion: Flu vaccine hesitancy among healthcare professionals can be a cause of morbidity and mortality for patients. Understanding the barriers and motivation for healthcare professionals to adhere to flu vaccination campaigns is crucial. Professionals who are asymptomatic carriers become sources of transmission. Annual vaccination, although safe and effective, faces variability due to antigenic concordance. In Portugal, educational and communication strategies are vital, highlighting the role of health professionals as models of preventive behavior. Easy access to medical consultations and Occupational Health recommendations is associated with greater adherence. In times of pandemic, the propensity for vaccination has increased, and it is important to promote this change. Strategies adapted to the cultural context are essential to boost adherence to Influenza vaccination among healthcare professionals. Conclusion: The approach to combating barriers and promoting vaccination among healthcare professionals must involve multiple areas and multiple levels, with communication targeted at specific groups, to increase its effectiveness. The message must be adapted to different population groups and different levels of health literacy. Knowing these behavioral determinants can help develop vaccination promotion campaigns from new perspectives and finding strategies to increase vaccination coverage is crucial for Occupational Health Services. Due to the ethical characteristics of the professions involved in providing direct care to patients, there is a need to reinforce the idea that vaccination among healthcare professionals is not only for their benefit, but above all for the protection of their patients.

RESUMO Introdução: A Gripe é uma ameaça global, com alto potencial epidémico e afeta anualmente entre 5 a 15% da população mundial. No ambiente hospitalar, a vacinação é crucial para proteger os Profissionais de Saúde. No entanto, apesar das recomendações internacionais, a adesão é baixa devido a preocupações de segurança e/ou desconfiança. Estudos mostram que os profissionais vacinados têm menores taxas de absentismo e, perante infeção pelo vírus, apresentam sintomatologia mais ligeira. Neste trabalho é realizado um estudo observacional transversal retrospetivo da taxa de vacinação contra esta doença numa população de trabalhadores de base hospitalar, no período de 2019 a 2023. Para compreender a importância da vacinação contra a Influenza nestes trabalhadores e quais os determinantes comportamentais que podem justificar esta evolução, realizou-se uma revisão dos desafios da vacinação entre Profissionais de Saúde, para identificar pontos chave e elaborar estratégias com o objetivo de promover a adesão às campanhas de vacinação. Metodologia: Para o estudo observacional da taxa de adesão à vacinação contra a Gripe num hospital periférico foram utilizados os dados de vacinação dos Profissionais de Saúde disponibilizados nos registos do Serviço de Saúde Ocupacional. A categoria profissional foi a única variável considerada. A análise dos dados foi realizada com o Microsoft® Excel®. Para a revisão recorreu-se às bases de dados Medline, Science Direct, Google Scholar; com as palavras-chave "Influenza vaccine”; “health professional” e “behaviour" e filtraram-se estudos de 2010 a 2024. Resultaram 1277 trabalhos e, após aplicar os critérios de exclusão, que incluíam vacinação para outras doenças e populações alvo que não os Profissionais de Saúde, foram selecionadas 22 fontes bibliográficas. Para espelhar a realidade nacional foram incluídos os artigos sobre o tema publicados pela Revista Portuguesa de Saúde Ocupacional Online, assim como estudos complementares e documentos de referência. Resultados: O estudo da adesão à vacinação contra a Gripe neste hospital periférico a Lisboa, entre 2019 e 2023, mostrou uma variação na adesão à vacinação, com uma média de 30%, valor abaixo dos valores reportados noutros países. As categorias com maior hesitação a esta vacina foram o Pessoal de Enfermagem e os Assistentes Técnicos. Na situação oposta estavam o Pessoal Médico e os Assistentes Técnicos. Durante a Pandemia COVID-19 existiu um número crescente de profissionais vacinados anualmente, tendo esta tendência invertido após o fim da emergência global desta doença. Da revisão da bibliografia sobre a hesitação vacinal destaca-se 8 dos 14 domínios comportamentais que representam as teorias de mudança comportamental que constituem fatores modificáveis que influenciam a atitude em relação à vacina. Abordou-se sobre esta perspetiva cada um deles, nomeadamente, o conhecimento; o contexto ambiental e recursos; influência social; crenças e conhecimento sobre consequências; bem como sobre a capacidade individual; identidade e papel social/profissional; reforço e emoção. Discussão: A hesitação vacinal contra a Gripe entre Profissionais de Saúde pode ser uma causa de morbilidade e mortalidade para os doentes. Compreender as barreiras e motivação para a adesão dos Profissionais de Saúde às campanhas de vacinação contra a Gripe é crucial. Profissionais portadores assintomáticos, tornam-se fontes de transmissão. A vacinação anual, embora segura e eficaz, enfrenta variabilidade devido à concordância antigénica. Em Portugal, estratégias educacionais e de comunicação são vitais, destacando o papel dos Profissionais de Saúde como modelos de comportamento preventivo. O acesso fácil a consultas médicas e tal ser recomendado pela Saúde Ocupacional é associado a maior adesão. Em tempos de pandemia, a propensão à vacinação aumentou, importando promover esta mudança. Estratégias adaptadas ao contexto cultural são essenciais para impulsionar a adesão à vacinação contra a Gripe entre Profissionais de Saúde. Conclusão: A abordagem para combater as barreiras e promover a vacinação nos Profissionais de Saúde deve envolver múltiplas áreas e vários níveis, com uma comunicação dirigida a grupos específicos, para aumentar a sua eficácia. Deve adaptar-se a mensagem aos diferentes grupos populacionais e aos diferentes níveis de literacia em saúde. Conhecer estes determinantes comportamentais pode ajudar a desenvolver campanhas de promoção da vacinação a partir de novas perspetivas e encontrar estratégias para aumentar a cobertura vacinal é crucial para os Serviços de Saúde Ocupacional. Pelas características éticas das profissões envolvidas na prestação de cuidados diretos aos doentes, existe a necessidade de reforçar a ideia de que a vacinação entre Profissionais de Saúde não é apenas para seu benefício mas, acima de tudo, para proteção dos seus doentes.

BACKGROUND: Dentistry is regarded as a high-risk profession due to increased levels of exposure to oral secretions, aerosols and fomites that harbour infectious microorganism. Yet evidence indicates poor uptake of vaccines against HBV and, most recently, Covid-19. This study sought to investigate the predictors of Covid-19 vaccination intention among oral health professionals in South Africa. METHODOLOGY: In 2022, a representative national sample of oral health professionals was surveyed using an online questionnaire. Consenting practitioners provided demographic data, information on vaccination history and five psychological antecedents of Covid-19 vaccine. Data analysis was undertaken using SPSS ver. 29.0. RESULTS: Our findings indicate high vaccination intention rate among the OHPs (77.9%), especially those with history of influenza vaccination (OR=2.65, p=0.003). The was a positive correlation between the 5C psychological antecedents (confidence and collective benefit) and intention to vaccinate. Positive Covid-19 diagnosis did not affect vaccination intention. CONCLUSION: Most oral health professionals intended to get the Covid-19 vaccination. For those showing low willingness to vaccinate, psychological antecedent factors such as complacency and calculation should be addressed to improve vaccination intention and uptake.

RESUMEN Introducción: A nivel mundial, la cobertura de vacunación contra el COVID-19, así como contra la influenza es baja tanto en la población general como en los profesionales de la salud a pesar de que la vacuna es gratuita y obligatoria en el personal sanitario. Objetivo: Describir la cobertura de vacunación contra el COVID -19, y la influenza en personal de salud y administrativo de un hospital de referencia del Ministerio de Salud Pública y Bienestar Social en el periodo 2021-2022. Metodología: Estudio observacional descriptivo de corte trasverso. Se hizo la revisión de los registros del personal sanitario y administrativo del centro vacunatorio del Hospital Nacional de Itauguá de la campaña vacunal contra el COVID-19 y de anti-influenza en el periodo 2021- 2022. Resultados: De los 3.586 funcionarios, 999 (27,9 %) eran médicos, 1494 (41,7 %) personal de enfermería, 366 (10,2 %) otra categoría de personal sanitario, y 727 (20,3 %) personal administrativo. En forma global, el 86,5 % de los funcionarios recibió por lo menos las dos dosis que constituyen el esquema primario y el 73 % la dosis de refuerzo. El 2,1 % del personal no recibió ninguna dosis de vacuna anti covid-19, la cifra fue mayor en el personal administrativo (4,8 %). La cobertura de vacunación contra la influenza fue de 20 % en el 2021 y 25 % en el 2022. Discusión: Si bien cobertura de vacunación anti-COVID-19 fue comparable a otros países, la vacunación contra la influenza fue muy baja. Es urgente implementar estrategias dirigidas a aumentar la percepción de riesgo y aceptabilidad de las vacunas obligatorias para el personal sanitario.

ABSTRACT Introduction: Worldwide, vaccination coverage against COVID-19, as well as against influenza, is low both in the general population and in health professionals, despite the fact that the vaccine is free and mandatory for health personnel. Objective: To describe the COVID -19 and influenza vaccination coverage in health and administrative personnel of a reference hospital of the Ministry of Public Health and Social Welfare in the period 2021-2022. Methods: Cross-sectional descriptive observational study. Charts of the health and administrative personnel of the vaccination center of the Itauguá National Hospital of the COVID-19 and influenza vaccination campaign in the period 2021-2022 were reviewed. Results: Of the 3,586 personnel, 999 (27.9%) were medical personnel, 1,494 (41.7%) nursing personnel, 366 (10.2%) other category of health personnel, and 727 (20.3%) administrative personnel. Overall, 86.5% of the employees received at least the two doses that constitute the primary schedule and 73% the booster dose; 2.1% of the staff did not receive any dose of the anti COVID-19 vaccine, which was higher in the administrative staff (4.8%). Influenza vaccination coverage was 20% in 2021 and 25% in 2022. Discussion: Even though the vaccination coverage of anti-COVID-19 was comparable to other countries, vaccination anti-influenza was very low. It is urgent to implement strategies aimed at increasing the perception of risk and acceptability of mandatory vaccines for health personnel.

ABSTRACT Cardiovascular diseases stand as the leading cause of mortality among adults globally. For decades, comprehensive evidence has underscored the correlation between infections, particularly those involving the respiratory system, and an elevated risk of cardiovascular and cerebrovascular events, as well as all-cause mortality. The mechanisms through which infections heighten cardiovascular events are intricate, encompassing immune system activation, systemic inflammation, hypercoagulable states, sympathetic system activation, and increased myocardial oxygen demand. Respiratory infections further contribute hypoxemia to this complex interplay. These mechanisms intertwine, giving rise to endothelial dysfunction, plaque ruptures, myocardial depression, and heart failure. They can either instigate de novo cardiovascular events or exacerbate pre-existing conditions. Compelling evidence supports the safety of influenza, pneumococcal, herpes zoster, COVID-19 and respiratory syncytial virus vaccines in individuals with cardiovascular risk factors or established cardiovascular disease. Notably, the influenza vaccine has demonstrated safety even when administered during the acute phase of a myocardial infarction in individuals undergoing angioplasty. Beyond safety, these vaccinations significantly reduce the incidence of cardiovascular events in individuals with an augmented cardiovascular risk. Nevertheless, vaccination rates remain markedly suboptimal. This manuscript delves into the intricate relationship between infections and cardiovascular events. Additionally, we highlight the role of vaccinations as a tool to mitigate these occurrences and reduce residual cardiovascular risk. Finally, we emphasize the imperative need to optimize vaccination rates among individuals with heart diseases.

RESUMEN Los adultos fumadores, con comorbilidades, y los ancianos tienen mayor riesgo de contraer infecciones pulmonares y de tener peor evolución. La neumonía adquirida en la comunidad debida a virus, neumococo, además de otras bacterias y microorganismos “atípicos” afecta tanto a adultos sanos como enfermos. La vacuna antigripal se diseña el verano anterior orientada a las cepas esperadas para la temporada siguiente. Su eficacia depende fundamentalmente de la variante viral que finalmente sea la responsable del brote. La vacuna anti-neumocócica polisacárida existe desde 1983 y será inexorablemente reemplazada por vacunas conjugadas de mayor eficacia, que previenen la infección por los serotipos presentes en la vacuna. La inmunización contra SARS-CoV-2 aceleró la reducción del contagio y la gravedad de COVID-19 notablemente. La vacuna acelular para Bordetella pertussis no está en el calendario de adultos, aun cuando vacunarlos fortalece el control del contagio infantil. La vacunas doble bacteriana (difteria y tétanos), y triple (doble + pertusis), y contra sarampión, varicela, rubeola, HPV, Haemophylus influenzae, meningococo, herpes zóster, fiebre hemorrágica argentina y fiebre amarilla están disponibles, pero son de uso limitado. Nuevas vacunas, como la recientemente aprobada por los CDC contra el virus sincicial respiratorio, pronto estarán disponibles.

ABSTRACT Adult smokers, subjects with comorbidities, and the elderly are at higher risk of pulmonary infections and worse outcomes. Community-acquired pneumonia due to viruses, pneumococcus, other bacteria, and “atypical” microorganisms affects healthy and sick adults. The flu vaccine is designed the previous summer for the strains expected for the following season. Its effectiveness depends fundamentally on the viral variant ultimately responsible for the outbreak. The anti-pneumococcal polysaccharide vaccine has been available since 1983 and it is expected to be replaced by conjugate vaccines which are more effective in preventing infection due to serotypes present in the vaccine. Immunization against SARS-CoV-2 diminished contagion and severity of COVID-19 remarkably. The acellular vaccine for Bordetella pertussis is not on the schedule for all adults, even when vaccinating them strengthens the control of contagion in children. Double bacterial (diphtheria and tetanus), triple (double + pertussis), measles, varicella, rubella, HPV, Haemophilus influenzae, meningococcal, herpes zoster, Argentine hemorrhagic fever, and yellow fever vaccines are available, but their use is limited. New vaccines such as the one recently approved by the CDC against respiratory syncytial virus will soon be available.

Resumen Los adultos fumadores con comorbilidades, y los ancianos, corren mayor riesgo de contraer infecciones y sus complicaciones. Las infecciones respiratorias comu nitarias por virus, neumococo y otras bacterias afectan tanto a adultos sanos como enfermos. Existen vacunas que el neumonólogo debe conocer y prescribir. Las ce pas blanco de la vacuna contra influenza son definidas por la OMS para el hemisferio sur considerando a las implicadas en la temporada precedente de influenza en el hemisferio norte. Su efectividad depende de la virulencia, la concordancia entre las cepas circulantes y las vacunales y la cobertura de la población. La vacuna anti-neumocócica polisacárida disponible desde 1983 está siendo reemplazada por vacunas conjugadas más eficaces para prevenir infecciones relacionadas a sero tipos presentes en las mismas. La inmunización contra SARS-CoV-2 redujo el contagio, la gravedad y la letalidad de COVID-19. La vacuna acelular contra Bordetella pertussis para adultos está presente para situaciones puntuales en el calendario para adultos, vacunarlos fortalece el control del contagio infantil. Las vacunas doble bacte riana (difteria + tétanos), y triple (doble + pertussis), y contra sarampión, varicela, rubeola, virus del papiloma humano, Haemophylus influenzae, meningococo, herpes zóster, fiebre hemorrágica argentina y fiebre amarilla, son de uso más limitado. Pronto contaremos con nuevas vacunas, como la recientemente aprobada por la FDA contra el virus sincicial respiratorio. Revisamos a través de un consenso de expertos en infecciones respiratorias las nuevas evidencias acerca de la inmunización de adultos que consultan al neumonólogo, y actualizamos así las recomendaciones sobre vacunación realizadas ocho años atrás.

Abstract Adult smokers, those with comorbidities, and the elderly, are at greater risk of contracting infections and their complications. Community acquired respiratory infections due to viruses, pneumococcus and other bac teria, affect both healthy and sick adults. There are vac cines that the pulmonologist must know and prescribe. The target strains of the influenza vaccine are defined by the WHO for the Southern hemisphere considering those involved in the previous influenza season in the Northern hemisphere. Its effectiveness depends on virulence, concordance between circulating and vaccine strains, and population coverage. The anti-pneumococcal polysaccharide vaccine available since 1983 is being replaced by more effective conjugate vaccines to pre vent infections related to serotypes present in them. Immunization against SARS-CoV-2 reduced the conta gion, severity, and lethality of COVID-19. The acellular vaccine against Bordetella pertussis for adults is present for specific situations in the adult calendar; vaccinating them strengthens the control of childhood contagion. The double (diphtheria + tetanus), and triple (double + pertussis) bacterial vaccines, and the vaccines against measles, chickenpox, rubella, human papillomavirus, Haemophilus influenzae, meningococcus, herpes zoster, Argentine hemorrhagic fever and yellow fever, are of a more limited use. Soon we will have new vaccines such as the one recently approved by the FDA against respi ratory syncytial virus. Through a consensus of experts in respiratory infections, we review the new evidence regarding the immunization of adults who consult a pulmonologist, and thus update the recommendations on vaccination made eight years ago.

SUMMARY OBJECTIVE: The aim of this study was to estimate the prevalence of influenza immunization in elderly people in Brazil in 2019. METHODS: This is a population-based cross-sectional study. The Brazilian individuals (≥60 years) who participated in the 2019 National Health Survey were included. The survey was conducted in permanent households in Brazil from August 2019 to March 2020. The prevalences of influenza vaccination and their respective confidence intervals (95%CI) were estimated according to sociodemographic characteristics and the diagnosis of chronic diseases. RESULTS: The prevalence of influenza vaccination was 72.4% (95%CI 71.5–73.2), with statistically significant differences observed between genders (p=0.001), age groups (p=0.001), and those living with a spouse/partner (p=0.002). Significant differences were found in groups with arterial hypertension (75.2%, p<0.001), diabetes (77.2%, p<0.001), and arthritis or rheumatism (75.5%, p<0.001). CONCLUSION: A global prevalence of influenza vaccination of 72.4% was estimated among elderly people in Brazil. OBJECTIVE METHODS populationbased population based crosssectional cross sectional ≥60 60 (≥6 years 201 included 2020 95%CI 95CI CI 95 diseases RESULTS 724 72 4 72.4 71.5–73.2, 715732 71.5–73.2 , 71 5 73 2 71.5–73.2) p=0.001, p0001 p p=0.001 0 001 (p=0.001) spousepartner spouse partner p=0.002. p0002 p=0.002 . 002 (p=0.002) 75.2%, 752 75 (75.2% p<0.001, p<0.001 p<0.001) 77.2%, 772 77 (77.2% 75.5%, 755 (75.5% p<0.001. CONCLUSION ≥6 6 (≥ 20 202 9 7 72. 71573 71.5–73. p000 p=0.00 00 (p=0.001 (p=0.002 75.2% (75.2 p<0.00 77.2% (77.2 75.5% (75.5 ≥ ( 7157 71.5–73 p00 p=0.0 (p=0.00 75.2 (75. p<0.0 77.2 (77. 75.5 715 71.5–7 p0 p=0. (p=0.0 75. (75 p<0. 77. (77 71.5– p=0 (p=0. (7 p<0 71.5 p= (p=0 p< 71. (p= (p

RESUMEN La gripe equina es una enfermedad viral muy contagiosa, especialmente entre los caballos jóvenes de 1 a 5 años de edad. La vacunación se considera la mejor forma de controlar la propagación y los brotes de la enfermedad. Aunque los potros son el principal animal utilizado para la evaluación de vacunas contra la gripe equina, en el presente trabajo se eligieron cobayos como modelo alternativo, ya que tienen un título insignificante de anticuerpos contra el virus de la gripe equina y son más baratos y fáciles de manejar que los potros. Se evaluaron cinco lotes de vacunas contra la gripe equina en dos modelos animales, potros y cobayos, mediante la inyección de dos dosis/animal con 4 semanas de intervalo utilizando 2 mL/animal/dosis y la evaluación de las respuestas inmunitarias mediante la prueba de inhibición de la hemaglutinación y el ensayo inmunoenzimático. En la 7ª semana posvacunación, los títulos de anticuerpos contra la gripe equina alcanzaron valores máximos de 9-10,2 y 8,7-10 unidades de inhibición de la hemaglutinación para potros y cobayos, respectivamente; las relaciones muestras/negativos fueron de 0,126-0,464 y 0,128-0,445 para ambos animales, respectivamente. Podría recomendarse el uso de cobayos como modelo animal para la evaluación de vacunas contra la gripe equina, en lugar de potros.

ABSTRACT Equine influenza is a highly contagious viral disease, specially among 1-5 years old naive horses. Vaccination is considered the best way to control the disease spread and outbreaks. Although foals are the main animal used for evaluation of equine influenza vaccines, guinea pigs were chosen as an alternative model in the present work, as they have a negligible antibody titer against equine influenza virus and are cheaper and easier to handle than foals. Five equine influenza vaccine batches were evaluated in two animal models, foals and guinea pigs, by injection of two doses/animal with 4 weeks apart using 2 mL/animal/dose and evaluation of immune responses by hemagglutination inhibition test and enzyme-linked immunosorbent assay. On the 7th week post vaccination, equine influenza antibodies titers reached maximum values of 9-10.2 and 8.7-10 hemagglutination inhibition units for foals and guinea pigs, respectively; sample/negative ratios were 0.126-0.464 and 0.128-0.445 for both animals, respectively. The use of guinea pigs as an animal model for the evaluation of equine influenza vaccines could be recommended instead of foals.

Abstract Background: Influenza-Associated Encephalopathy/Encephalitis (IAE) is characterized by high incidence and poor prognosis. The aim of this study is to describe the clinical features and outcomes of IAE in pediatric patients. Methods: We performed a retrospective review of hospitalized cases of laboratory-confirmed influenza infection between January 2018 and December 2021. Demographic, clinical, imaging, treatment and outcome data were collected. Statistical analysis was performed using SPSS software. Results: Of 446 children hospitalized with influenza, 71 cases were identified with a diagnosis of IAE. The median age was 3 years and 46 (64.8 %) were younger than 5 years. Only one patient was vaccinated for seasonal influenza. 46 (64.8 %) patients had abnormal electroencephalogram examination and 47 (66.2 %) had abnormal brain MRI or CT findings. 68 (95.8 %) patients were treated with oseltamivir/peramivir. 12 (16.9 %) patients suffered mortality. Non-survivors were more likely to have lower Glasgow coma score (median 7), longer duration of fever (median 3 days), with underlying medical conditions (P = 0.006), and complications including sepsis (P = 0.003), shock (P < 0.001), respiratory failure (P = 0.006), acute renal failure (P = 0.001), myocardial damage (P < 0.001), coagulation disorders (P = 0.03), electrolyte disturbance (P = 0.001) and hyperlactacidemia (P = 0.003). Non-survivors had higher percentages of corticosteroids (P = 0.003) and immunoglobulin (P = 0.003) treatments compared to survivors. Conclusions: Children with IAE have a high mortality rate. Lower Glasgow coma score, longer duration of fever, with underlying medical conditions and complications pose a great risk to poor prognosis. Influenza vaccination is recommended to all eligible children. Background InfluenzaAssociated Associated EncephalopathyEncephalitis Encephalopathy Encephalitis (IAE prognosis Methods laboratoryconfirmed laboratory confirmed 201 2021 Demographic imaging collected software Results 44 7 4 64.8 648 64 8 (64. % 66.2 662 66 2 (66. findings 6 95.8 958 95 (95. oseltamivirperamivir oseltamivir peramivir oseltamivir/peramivir 1 16.9 169 16 9 (16. Nonsurvivors Non survivors 7, , 7) days, days days) P 0.006, 0006 0.006 0 006 0.006) 0.003, 0003 0.003 003 0.001, 0001 0.001 001 0.03, 0.03 03 0.03) 0.003. . Conclusions rate 20 202 64. (64 66. (66 95. (95 16. (16 000 0.00 00 0.0 (6 (9 (1 0. (

ABSTRACT Objective: The aim of the study was to assess the impact of the Gamma coronavirus disease 2019 (COVID-19) variant on pregnant and postpartum women with Cardiovascular Disease (CVD). Methods: The Influenza Epidemiological Surveillance System database (SIVEP-Gripe), a compulsory notification system for cases of Severe Acute Respiratory Syndrome (SARS), was investigated for notified cases of pregnant and postpartum women with reported CVD and SARS due to COVID-19 between February 16, 2020 and May 1, 2021 (when vaccination began), was investigated. In this retrospective cohort, two groups were formed based on symptom onset date, according to the predominance of the variants: original (group 2020) and Gamma (group 2021). Cases with missing information on the presence or absence of CVD were excluded. The comparative analysis was controlled for confounding variables. Results: Among 703 COVID-19 cases notified with CVD (406 patients in 2020 and 297 patients in 2021), compared to 2020, cases in 2021 had more respiratory symptoms (90.6 % vs. 80.1 %, p < 0.001), greater ventilatory support need (75.3 % vs. 53.9 %, p < 0.001), more ICU admission (46.6 % vs. 34.3 %, p = 0.002), longer duration (20.59 ± 14.47 vs. 16.52 ± 12.98 days, p < 0.001), higher mortality (25.6 % vs. 15.5 %, p < 0.001), with more than two-times mortality likelihood in the third trimester (adjusted OR = 2.41, 95 % CI 1.50–3.88, p < 0.001) or puerperium periods (adjusted_OR = 2.15, 95 % CI 1.34-3.44, p = 0.001). Conclusions: In Brazil, pregnant and postpartum women with CVDs in the Gamma variant phase have higher morbidity and mortality than those affected by the original variant of Coronavirus-19. Objective 201 COVID19 COVID 19 (COVID-19 CVD. . (CVD) Methods SIVEPGripe, SIVEPGripe SIVEP Gripe , (SIVEP-Gripe) SARS, (SARS) COVID-1 16 202 1 when began, began began) cohort date variants group 2021. 2021) excluded variables Results 70 406 (40 29 2021, 90.6 906 90 6 (90. vs 801 80 80. 0.001, 0001 0.001 0 001 75.3 753 75 3 (75. 539 53 9 53. 46.6 466 46 (46. 343 34 34. 0.002, 0002 0.002 002 0.002) 20.59 2059 20 59 (20.5 1447 14 47 14.4 1652 52 16.5 1298 12 98 12.9 days 25.6 256 25 (25. 155 15 5 15. twotimes times adjusted 241 2 41 2.41 150388 50 88 1.50–3.88 adjusted_OR adjustedOR 215 2.15 1.343.44, 134344 1.34 3.44, 44 1.34-3.44 0.001. Conclusions Brazil Coronavirus19. Coronavirus19 Coronavirus 19. Coronavirus-19 COVID1 (COVID-1 (CVD (SIVEP-Gripe (SARS COVID- 7 40 (4 90. (90 8 000 0.00 00 75. (75 46. 4 (46 20.5 205 (20. 144 14. 165 16. 129 12. 25. (25 24 2.4 15038 1.50–3.8 21 2.1 1.343.44 13434 134 1.3 344 3.44 1.34-3.4 Coronavirus1 Coronavirus-1 (COVID- ( (9 0.0 (7 20. (20 (2 2. 1503 1.50–3. 1.343.4 1343 13 1. 3.4 1.34-3. Coronavirus- (COVID 0. 150 1.50–3 1.343. 3. 1.34-3 1.50– 1.343 1.34- 1.50 1.5

Abstract: Introduction: the vaccination program is a public health intervention aimed at controlling or eliminating vaccine-preventable diseases. The objective of the study was to estimate the evolution of the vaccine budget between 2007 and 2022 and the impact of potential improvements in Paraguay’s vaccination schedule. Method: the evolution of the vaccine budget was estimated considering the changes introduced between 2007 and 2022 and the impact of alternative schedules versus the current one. These alternatives include the addition of the quadrivalent influenza vaccine, the hexavalent vaccine for infants, the inclusion of the HPV vaccine for boys, and the ACYW meningococcal ACYW vaccine for adolescents. The analysis was conducted from the perspective of the Ministry of Health, with a time horizon of one year. The results of the alternatives are expressed as budget impact compared to the year 2022. Results: between 2007 and 2022, the number of biological products in the EPI increased from 11 to 18, and additional indications for some vaccines were incorporated. The budget is estimated to have increased from 3.8 to 29.9 million USD over the series. The alternatives would result in individual increases of 13%, 35%, 5%, and 10%. The combined increase reaches 62%. Conclusions: the increase in vaccine expenditure was eightfold between 2007 and 2022. The budget impact was estimated in different scenarios, interpreted as improvements compared to the current 2022 scenario, with the most demanding increase being 35%. The generated evidence can assist in the decision-making process regarding this public policy in Paraguay.

Resumo: Introdução: o programa de vacinação é uma intervenção de saúde pública cuja finalidade é controlar ou eliminar doenças imunopreveníveis. O objetivo deste estudo foi estimar a evolução do orçamento de vacinas entre 2007 e 2022 e o impacto de possíveis melhorias no cronograma de vacinação do Paraguai. Métodos: estimamos a evolução do orçamento de vacinas de acordo com as mudanças ocorridas entre 2007 e 2022 e o impacto de esquemas alternativos em relação ao atual, que incluem a vacina quádrupla contra a gripe, a sextupla em bebês, a adição da vacina contra o papilomavírus em homens e a vacina meningocócica ACYW em adolescentes. A perspectiva da análise foi a do Ministerio de Salud e o intervalo de tempo foi de um ano. Os resultados das alternativas são expressos como impacto orçamentário em relação a 2022. Resultados: Entre 2007 e 2022, o número de produtos biológicos do PAI aumentou de 11 para 18 e incorporou indicações para algumas vacinas. Estima-se que o orçamento tenha aumentado de US$ 3,8 milhões para US$ 29,9 milhões entre os extremos da série. As alternativas implicariam em um aumento de 13%, 35%, 5% e 10% individualmente. O aumento geral chega a 62%. Conclusões: o aumento nos gastos com vacinas foi de oito vezes entre 2007-2022. O impacto orçamentário é estimado em diferentes cenários que são interpretados como melhorias em comparação com o cenário de 2022, sendo que o aumento mais exigente é de 35%. As evidências geradas podem contribuir para o processo de tomada de decisão relacionado a essa política pública no Paraguai.

Resumen: Introducción: el programa de vacunación es una intervención de salud pública cuyo propósito es controlar o eliminar enfermedades inmunoprevenibles. El objetivo de este trabajo fue estimar la evolución del presupuesto en vacunas entre 2007 y 2022, y el impacto de potenciales mejoras en el calendario de vacunaciones de Paraguay. Método: se estimó la evolución del presupuesto en vacunas según los cambios entre 2007 y 2022, y el impacto de esquemas alternativos versus el actual, que incluyen la vacuna contra la influenza cuádruple, séxtuple en lactantes, el agregado de la vacuna contra papiloma en varones y meningococo ACYW en adolescentes. La perspectiva del análisis fue la del Ministerio de Salud Pública y el horizonte temporal de un año. Los resultados de las alternativas se expresan como impacto presupuestal versus el año 2022. Resultados: entre 2007 y 2022 la cantidad de biológicos del Programa Ampliado de Inmunizaciones pasó de 11 a 18 e incorporó indicaciones de algunas vacunas. Se estima que el presupuesto se incrementó de 3,8 a 29,9 millones de dólares entre los extremos de la serie. Las alternativas implicarían un incremento de 13%, 35%, 5% y 10%, individualmente. El incremento en conjunto alcanza el 62%. Conclusiones: el aumento del gasto en vacunas fue de ocho veces entre 2007 y 2022. Se estima el impacto presupuestal en diferentes escenarios que se interpretan como mejoras comparadas con el actual de 2022, siendo el incremento más exigente de un 35%. La evidencia generada puede colaborar en el proceso de toma de decisiones acerca de esta política pública en Paraguay.

RESUMEN Introducción: las defunciones por influenza en niños se asociaron en un 92,5% a la ausencia de vacunación. Muchos padres han expresado cierta inquietud, la que los ha llevado a posponer algunas vacunas o hasta suspenderlas por completo. Objetivo: validar un instrumento para identificar el riesgo de la no vacunación contra influenza en derechohabientes de menores de cinco años. Métodos: estudio descriptivo, transversal. Con un universo de 3 292 padres de niños menores de cinco años, con una muestra probabilística de 345 padres adscritos a la Unidad Médico Familiar No.1 entre noviembre de 2021 a febrero de 2022. Se diseñó un instrumento con el que se realizó la determinación de medidas de tendencia central y de dispersión. Para la congruencia interna y la validación del instrumento se calculó el Alpha de Cronbach. Resultados: 127 niños (36,8%) contaban con esquema de vacunación incompleto y 114 niños (33%) con esquema incompleto de la influenza. Hubo relación entre la escolaridad materna y la falta de la vacuna contra la influenza. De acuerdo con el riesgo de la no vacunación en futuras aplicaciones de vacunas, solo 15 niños (4,3%) presentaron un alto riesgo. Específicamente de la vacuna de la influenza, se aplicó la prueba de congruencia interna con Alpha de Cronbach a cada ítem y se obtuvo una alta confiabilidad. Conclusiones: el instrumento “Escala de riesgo para la no vacunación en el menor de cinco años” presentó una gran confiabilidad con un Alpha de Cronbach mayor de 0,9. La desinformación fue el principal factor de riesgo para la no vacunación.

ABSTRACT Introduction: 92.5% of influenza deaths in children were associated with the absence of vaccination. Many parents have expressed some concern, which has led them to postpone some vaccinations or even to suspend them completely. Objective: to validate an instrument to identify the risk of non-vaccination against influenza in rightful claimants under five years of age. Methods: descriptive, cross-sectional study. With a universe of 3,292 parents of children under five years of age, with a probabilistic sample of 345 parents assigned to the Family Medical Unit No. 1 between November 2021 and February 2022. An instrument was designed to determine measures of central tendency and dispersion. Cronbach's Alpha was calculated for internal congruence and validation of the instrument. Results: 127 children (36.8%) had incomplete vaccination schedules and 114 children (33%) had incomplete influenza vaccination schedules. There was a relationship between maternal schooling and lack of influenza vaccination. According to the risk of non-vaccination in future vaccine applications, only 15 children (4.3%) presented a high risk. Specifically for the influenza vaccine, the internal congruence test with Cronbach's Alpha was applied to each item and a high reliability was obtained. Conclusions: the instrument “Risk scale for non-vaccination in children under five years of age” showed high reliability with a Cronbach's Alpha greater than 0.9. Misinformation was the main risk factor for non-vaccination.

ABSTRACT The vaccine decision of health professionals has been observed in different countries, due to their hesitation behavior in the face of vaccination against COVID-19, which can interfere with the control of the pandemic. It was intended to identify the factors associated with the vaccination decision of health professionals against COVID-19 in publications from July 2020 to July 2022. An Integrative Literature Review was carried out in PubMed, Scopus, Web of Science and CINAHL databases. Of the 439 publications, 35 articles were chosen for analysis. The sociodemographic characteristics of the vaccine decision revealed that non-medical professionals, mainly nurses, had greater vaccine hesitancy. The study revealed factors associated with vaccine hesitancy, such as: doubts about the effectiveness of vaccines and the production process, insecurity due to lack of studies, fear of side effects and information conveyed on social media. Regarding vaccine acceptance and recommendation, prior vaccination against influenza, confidence in the effectiveness of vaccines and fear of the risk of contagion by COVID-19 stand out. Identifying the factors associated with the vaccination decision of health professionals against COVID-19 was strategic in relation to expanding vaccination coverage, both to protect the health of professionals and the population. countries COVID19, COVID19 COVID 19, 19 pandemic COVID-1 202 2022 PubMed Scopus databases 43 3 analysis nonmedical non medical nurses hesitancy as process studies media recommendation influenza coverage population COVID1 1 COVID- 20 4 2

RESUMO A decisão vacinal de profissionais de saúde tem sido observada em diferentes países, devido ao seu comportamento de hesitação frente à vacinação contra a Covid-19, que pode interferir no controle da pandemia. Pretendeu-se identificar os fatores associados à decisão vacinal de profissionais de saúde contra a Covid-19 em publicações de julho de 2020 a julho de 2022. Foi realizada uma revisão integrativa da literatura nas bases de dados PubMed, Scopus, Web of Science e Cinahl. Das 439 publicações, foram escolhidos 35 artigos para análise. As características sociodemográficas da decisão vacinal revelaram que profissionais não médicos, principalmente enfermeiros, apresentaram maior hesitação. O estudo revelou fatores associados à hesitação vacinal, tais como: dúvidas sobre a eficácia das vacinas e o processo de produção, insegurança pela escassez de estudos, medo dos efeitos colaterais e informações veiculadas em mídias sociais. Em relação à aceitação e à recomendação vacinal, ressaltam-se a vacinação prévia contra a influenza, a confiança na eficácia das vacinas e o receio pelo risco de contágio por Covid-19. A identificação dos fatores associados à decisão vacinal de profissionais de saúde contra a Covid-19 foi estratégica em relação à ampliação da cobertura vacinal, tanto para a proteção da saúde dos profissionais quanto para a da população. países Covid19, Covid19 Covid 19, 19 pandemia Pretendeuse Pretendeu se Covid-1 202 2022 PubMed Scopus Cinahl 43 3 análise médicos enfermeiros como produção estudos sociais ressaltamse ressaltam influenza Covid19. 19. população Covid1 1 Covid- 20 4 2

ABSTRACT INTRODUCTION: The infection by the Influenza virus is considered a public health problem, causing severe illness and death, above all, in high-risk population. The vaccination against Influenza has proved to be effective in protecting patients and health professionals from nosocomial infections and in reducing absenteeism due to illness. Pityriasis Lichenoides represent a group of inflammatory skin diseases with a variable clinical spectrum. Cases of Pityriasis Lichenoides related to vaccination are rare, therefore, this work represents an opportunity to report about this syndrome, whilst contributing to the identification and clarification of one of the possible adverse effects of vaccination against Influenza. CASE DESCRIPTION: We report a case of 59-years-old health professional man, who attended an Occupational Medicine consultation due to the arising of a three days evolution erythematous papules on the trunk, abdomen and upper limbs, associated with pruritus, after carrying out Influenza vaccine (Influvac Tetra(), as part of the seasonal flu vaccination program at the Occupational Health Service. The diagnosis of Pityriasis Lichenoides induced by the Influenza vaccine was considered due to the clinical and histopathological data. DISCUSSION: Amongst the general literature, there are few reported cases of Pityriasis Lichenoides in connection with Influenza vaccination. The most frequently associated vaccines are the anti-measles, anti-mumps, and anti-rubella, and only one case is reported with direct link to the vaccine against Influenza. The article has the particularity of focusing on a case over a health professional which carries a greater risk of exposure to the virus, resulting from professional activity. Nevertheless, is a chronic patient (diabetic) and at a higher risk of serious illness/complications. CONCLUSIONS: Despite being a rare syndrome, we emphasize the right for a correct recognition, diagnosis and approach to this disease. Furthermore, the adherence to Influenza vaccination is strongly linked to the fear of adverse effects, which makes it crucial to train professionals involved in Influenza vaccination for correct counseling and follow-up in the vaccination process.

RESUMO INTRODUÇÃO: A infeção pelo vírus Influenza constitui um problema de saúde pública, causadora de doença grave e morte, sobretudo nas populações de risco elevado. A vacinação contra Influenza, tem se mostrado eficaz na proteção dos doentes e dos profissionais de saúde, das infeções nosocomiais e na redução do absentismo por doença. As Pitiríases Liquenoides representam um grupo doenças inflamatórias da pele com um espectro clínico variável. São raros os casos descritos na literatura científica de Pitiríase Liquenoide em associação com a vacinação, constituindo este trabalho uma oportunidade de reportar esta rara identidade, contribuindo paralelamente para o registo e clarificação de um dos possíveis efeitos adversos da vacinação contra Influenza. DESCRIÇÃO DO CASO: Descreve-se o caso de um homem, 59 anos, profissional de saúde, que recorre à consulta de Medicina do Trabalho pelo aparecimento de pápulas eritematosas no tronco, abdómen e membros superiores associado a prurido com cerca de três dias de evolução, após a realização de vacina contra vírus Influenza (Influvac Tetra(), no âmbito do programa de vacinação sazonal contra a gripe no Serviço de Saúde Ocupacional. O diagnóstico de Pitiríase Liquenoide induzido pela vacina da gripe foi estabelecido, tendo em conta os dados clínicos e histopatológicos. DISCUSSÃO: Na literatura, existem poucos casos relatados de Pitiríase Liquenoide em associação com a vacinação. O tipo de vacina mais frequentemente associada é a vacina anti-sarampo, anti-parotidite e anti-rubéola, sendo que apenas foi encontrado um caso descrito relativamente à vacina contra Influenza. Neste relato, existe a particularidade de se tratar de um profissional de saúde e, por isso, com maior risco de exposição ao vírus decorrente da atividade profissional. Paralelamente, acrescenta-se o facto de se tratar de um doente crónico (diabético) e com maior risco de doença grave/complicações. CONCLUSÕES: Apesar de rara, enfatizamos a necessidade de um correto reconhecimento, diagnóstico e abordagem desta patologia. Acrescenta-se que adesão à vacinação Influenza está fortemente ligada ao receio de efeitos adversos pelo que se torna fundamental capacitar os profissionais envolvidos na vacinação contra Influenza para um correto aconselhamento e acompanhamento no processo de vacinação.