Vacunas en situaciones especiales. Embarazo, inmunodepresión, transplante

En las recomendaciones de vacunación de grupos de población que por su situación de salud requieren medidas específicas deben conjugarse: Las limitaciones en la aplicación de determinadas vacunas por la mayor probabilidad de efectos secundarios en estos pacientes (por ejemplo la aplicación de vacunas de virus vivos en pacientes inmunodeprimidos). El mayor riesgo de infección frente a determinados agentes que genera la patología o situación inmunitaria del paciente, y que determina un mayor interés sanitario de la aplicación de las vacunas frente a los mismos. La menor respuesta inmunitaria a las vacunas, por la menor capacidad de respuesta del sistema inmune de estos pacientes. La consideración de estos tres factores, en el marco de una creciente evidencia de la importancia sanitaria de las estrategias de vacunación diseñadas específicamente para cada grupo de pacientes por los efectos protectores y la disminución de la incidencia o gravedad de las infecciones frente a las que se ha inmunizado, está llevando, en la última década, al diseño de calendarios de vacunación específicos, así como a un creciente impulso de estrategias de vacunación específicas para garantizar la captación y cumplimiento de estos calendarios. En este artículo se revisan las siguientes situaciones: Embarazo; Inmunosupresión ; Inmunodepresión ; Trasplante de progenitores hematopoyéticos ; Asplenia ; Trasplante de órganos sólidos. Se reseña la importancia de que toda mujer esté protegida frente a la rubéola antes del embarazo, y de la administración de esta vacuna en el post-parto a aquellas mujeres que no hubieran sido vacunadas previamente. Así mismo se insiste en la necesidad de la vacunación antigripal anual en el 2º o 3º trimestre del embarazo y de la importancia de la vacunación frente al tétanos antes del parto en las mujeres que no hayan completado previamente su vacunación. El paciente receptor de progenitores hematopoyéticos, independientemente de la edad, requiere la revacunación con todas las vacunas del calendario infantil, a las que debe añadirse la vacuna antineumocócica, antihaemophilus influenzae tipo b y antigripal, además de otras vacunas vinculadas a riesgos individuales. Los pacientes asplénicos presentan un alto riesgo de infecciones provocadas por bacterias capsuladas, por lo que cobra especial trascendencia la vacunación frente al neumococo, el Hib y el meningococo, además de la vacunación antigripal anual. Los pacientes sometidos a programa de trasplante de órgano sólido suponen un colectivo específico en el que debe programarse la aplicación de las vacunas antes del trasplante dada la mejor respuesta inmune en ese momento, y la vacunación postrasplante, según la situación inmune previa. Se destaca la importancia de la prevención pretrasplante frente a la varicela y la hepatitis B, así como las recomendaciones específicas de vacunación según el tipo de trasplante: frente al neumococo, el Haemophilus influenzae tipo b, la gripe, la Hepatitis A, etc, además de completar el calendario de vacunación infantil en los menores de 14 años, y de estar vacunado frente al tétanos, difteria, sarampión, rubéola, parotiditis y gripe anualmente en los adultos. Un aspecto a resaltar es la importancia de la vacunación del entorno del paciente inmunodeprimido, en especial en caso de trasplante, así como las consideraciones a tener en cuenta en las vacunas recomendadas a los convivientes

Cancer screening in Spain

Objective: To describe the current status of breast, colorectal and cervical cancer screening in Spain. Methodology: The situation was analysed on the basis of data drawn from surveys conducted in each autonomous region (Comunidad Autónoma). Results: Currently, breast cancer screening coverage is 100%. In 2007, overall participation was 67.0% with an adherence of 91.2%. The detection rate was 3.4 per thousand, 15.1% intraductal and 30% invasive <1 cm in diameter, with 65% showing axilary node negative. Colorectal cancer screening had been implemented in six regions (4.5% of the target population). Participation ranged from 17.2% to 42.3%, with positive test percentages ranging from 1.7 per thousand (guaiac) to 9.5% (immunological). The invasive cancer detection rate was 1.7 per thousand (guaiac) and 3.4 per thousand (immunological). In most cases, cervical cancer screening was undertaken opportunistically, with an estimated coverage of 69.0%. Conclusions: In Spain, cancer screening is being conducted in accordance with national and international recommendations. The fact that screening programmes are operated as a network has led to a high degree of consensus as to the methodology and information systems to be used to enable joint evaluation

Effect of protocol-related variables and women's characteristics on the cumulative false-positive risk in breast cancer screening

Background: Reducing the false-positive risk in breast cancer screening is important. We examined how the screening-protocol and women's characteristics affect the cumulative false-positive risk. Methods: This is a retrospective cohort study of 1 565 364 women aged 45-69 years who underwent 4 739 498 screening mammograms from 1990 to 2006. Multilevel discrete hazard models were used to estimate the cumulative false-positive risk over 10 sequential mammograms under different risk scenarios. Results: The factors affecting the false-positive risk for any procedure and for invasive procedures were double mammogram reading [odds ratio (OR) = 2.06 and 4.44, respectively], two mammographic views (OR = 0.77 and 1.56, respectively), digital mammography (OR = 0.83 for invasive procedures), premenopausal status (OR = 1.31 and 1.22, respectively), use of hormone replacement therapy (OR = 1.03 and 0.84, respectively), previous invasive procedures (OR = 1.52 and 2.00, respectively), and a familial history of breast cancer (OR = 1.18 and 1.21, respectively). The cumulative false-positive risk for women who started screening at age 50-51 was 20.39% [95% confidence interval (CI) 20.02-20.76], ranging from 51.43% to 7.47% in the highest and lowest risk profiles, respectively. The cumulative risk for invasive procedures was 1.76% (95% CI 1.66-1.87), ranging from 12.02% to 1.58%. Conclusions: The cumulative false-positive risk varied widely depending on the factors studied. These findings are relevant to provide women with accurate information and to improve the effectiveness of screening programs

Trends in detection of invasive cancer and ductal carcinoma in situ at biennial screening mammography in spain : A retrospective cohort study

Background: Breast cancer incidence has decreased in the last decade, while the incidence of ductal carcinoma in situ (DCIS) has increased substantially in the western world. The phenomenon has been attributed to the widespread adaption of screening mammography. The aim of the study was to evaluate the temporal trends in the rates of screen detected invasive cancers and DCIS, and to compare the observed trends with respect to hormone replacement therapy (HRT) use along the same study period. Methods: Retrospective cohort study of 1,564,080 women aged 45-69 years who underwent 4,705,681 screening mammograms from 1992 to 2006. Age-adjusted rates of screen detected invasive cancer, DCIS, and HRT use were calculated for first and subsequent screenings. Poisson regression was used to evaluate the existence of a change-point in trend, and to estimate the adjusted trends in screen detected invasive breast cancer and DCIS over the study period. Results: The rates of screen detected invasive cancer per 100.000 screened women were 394.0 at first screening, and 229.9 at subsequent screen. The rates of screen detected DCIS per 100.000 screened women were 66.8 at first screen and 43.9 at subsequent screens. No evidence of a change point in trend in the rates of DCIS and invasive cancers over the study period were found. Screen detected DCIS increased at a steady 2.5% per year (95% CI: 1.3; 3.8), while invasive cancers were stable. Conclusion: Despite the observed decrease in breast cancer incidence in the population, the rates of screen detected invasive cancer remained stable during the study period. The proportion of DCIS among screen detected breast malignancies increased from 13% to 17% throughout the study period. The rates of screen detected invasive cancer and DCIS were independent of the decreasing trend in HRT use observed among screened women after 2002

CanScreen5, a global repository for breast, cervical and colorectal cancer screening programs

The CanScreen5 project is a global cancer screening data repository that aims to report the status and performance of breast, cervical and colorectal cancer screening programs using a harmonized set of criteria and indicators. Data collected mainly from the Ministry of Health in each country underwent quality validation and ultimately became publicly available through a Web-based portal. Until September 2022, 84 participating countries reported data for breast (n = 57), cervical (n = 75) or colorectal (n = 51) cancer screening programs in the repository. Substantial heterogeneity was observed regarding program organization and performance. Reported screening coverage ranged from 1.7% (Bangladesh) to 85.5% (England, United Kingdom) for breast cancer, from 2.1% (Côte d’Ivoire) to 86.3% (Sweden) for cervical cancer, and from 0.6% (Hungary) to 64.5% (the Netherlands) for colorectal cancer screening programs. Large variability was observed regarding compliance to further assessment of screening programs and detection rates reported for precancers and cancers. A concern is lack of data to estimate performance indicators across the screening continuum. This underscores the need for programs to incorporate quality assurance protocols supported by robust information systems. Program organization requires improvement in resource-limited settings, where screening is likely to be resource-stratified and tailored to country-specific situations.</p