Clinical-epidemiological study of Bordetella pertussis infection in the Gran Canaria island in the period, 2008–2016

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In recent years, there has been evidence of an increased incidence in many countries with a high vaccination coverage.<a class="elsevierStyleCrossRefs" href="#bib0115">1,2</a> Variations in published incidence rates may be due to differences in case reporting systems and access to diagnostic tests,<a class="elsevierStyleCrossRefs" href="#bib0120">2–4</a> but the highest rates are always reported in infants aged less than 1 year, who also experience the most complications and highest mortality. The Canary Islands is one of the autonomous communities in Spain with the highest rates of infection.<a class="elsevierStyleCrossRef" href="#bib0135">5</a> In the 2003–2007 period, we performed a study where we found a high incidence of complications and mortality in this age group.<a class="elsevierStyleCrossRef" href="#bib0140">6</a> For this reason, since 2015, vaccination of pregnant women was introduced in our autonomous community. In order to determine the subsequent trends of infection, we have conducted a clinical-epidemiological study of all the cases diagnosed in infants aged less than 1 year that visited the emergency department of the only public paediatric hospital in the island of Gran Canaria between 2008 and 2016.Patients and methodsPatientsThe study included the 1,040 patients aged less than 1 year that visited the emergency department of the Hospital Materno Infantil de Gran Canaria (which serves an average of 6,770 infants aged less than 1 year) with a clinical presentation that required ruling out B. pertussis between January 2008 and December 2016.MethodsAll patients underwent testing for detection of B. pertussis by means of polymerase chain reaction (PCR) (LightMix Kit Bordetella pertussis/parapertussis or Diagenode Bordetella pertussis/parapertussis) in samples of nasopharyngeal exudate obtained with a flexible swab. Viral detection tests were also performed 581patients (55.9%) in nasopharyngeal aspirate samples.We performed a retrospective review of the health records of patients who tested positive for B. pertussis, collecting data on demographic variables, vaccination history, probably source of infection (contacts with clinical features compatible with pertussis), symptoms, laboratory data and treatment.In the statistical analysis, we used the Mann–Whitney U test to compare quantitative variables and the chi square test to compare proportions. We defined statistical significance as a p-value of less than .05. The study was approved by the local bioethics and research committee.ResultsEpidemiologyInfection by B. pertussis was detected in 110 patients (10.6%). A different pathogen was identified in 269 patients (25.7%): respiratory syncytial virus in 175, rhinovirus in 33, parainfluenzavirus 3 in 32, metapneumovirus in 7, cytomegalovirus in 5, influenza A in 5, influenza B in 4, enterovirus in 3, parainfluenzavirus 1 in 2, parainfluenzavirus 2 in 2, and coxsackievirus B in 1.Of the 110 infants with infection by B. pertussis, 65 were male (59.1%). The mean age was 83.3 days (range, 14–287 days), and 105 (95.4%) were aged less than 6 months. Eleven had been born preterm (10.0%).<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the annual incidence of pertussis cases per 100000 infants aged less than 1 year that sought care in the hospital. The annual incidence ranged between 13.7 cases in 2009 and 425.0 cases in 2015, with 2 peaks in years 2011 and 2015. Since 2010, the year with the lowest incidence was 2016. When it came to the seasonal distribution, 33.6% of cases occurred in summer, 29.1% in spring, 19.1% in winter and 18.2% in autumn.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>As for the vaccination status of the patients, 56 infants (50.9%) had not started to receive routine vaccinations, 47 (42.7%) had received 1 dose, 5 (4.5%) 2 doses and 2 (1.8%) 3 doses. Only 1 child was incorrectly vaccinated for age.A probable source of infection was documented in 45 patients (40.9%), corresponding to household members in 44 cases (97.8%) and nosocomial infection in 1.Seventeen infants with pertussis were born after the introduction of vaccination of pregnant women; in 5 of these infants (29.4%) the mother had received the vaccine in the third trimester of pregnancy (one at 28 weeks, one at 31 weeks, timing not documented in the remaining 3). The mean age of these 5 infants was 2.8 months (range, 0–5 months).Clinical manifestations<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the clinical manifestations and abnormal laboratory findings in 110 patients. The characteristic clinical presentation consisted of whooping cough accompanied by cold symptoms, cyanosis and lymphocytosis. The only difference in clinical characteristics between older infants and infants aged less than 3 months was the development of pneumonia, which only occurred in those aged less than 3 months (p<.01). The mean time elapsed from onset of symptoms to the emergency department visit was 9.0±5.9 days (range, 1–28 days). A total of 107 patients were admitted to hospital (97.3%) for a mean length of stay of 10.7±7.3 days (range, 0–45 days).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Complications developed in 17 patients (15.4%): 10 cases of pneumonia and 7 of apnoea. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents the characteristics of the infants that developed complications: 82.3% had not started vaccination, and the rest had only received 1 dose. Nine infants with pneumonia were admitted to the intensive care unit (ICU). One girl aged 42 days (case 1) that was admitted to the ICU had originally presented with a leucocyte count of 27200cells/μL, but at 13 days from onset had developed hyperleukocytosis (103000 leucocytes/μL), so she underwent a double volume exchange transfusion. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the differences between infants that developed complications and infants that did not. Their comparison reveals that infants who developed complications were younger and that a higher proportion of patients in this group had not initiated routine vaccinations.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>All patients received treatment from the time of admission with azithromycin (10mg/kg/day) for 5 days (except 1 patient treated for 10 days), with favourable outcomes.Coinfection with other pathogensFifty-seven patients (51.8%) with infection B. pertussis underwent viral detection tests, which revealed in 18 (31.6%): by rhinovirus in 9, parainfluenzavirus 3 in 3, respiratory syncytial virus in 2, adenovirus in 1, influenza C in 1, cytomegalovirus in 1 and coxsackievirus B in 1.DiscussionDespite the high vaccination coverage in the paediatric population, pertussis continues to be a significant health problem that recently led to the introduction of vaccination of pregnant women in the autonomous community of the Canary Islands with the intent to protect infants, the most vulnerable subset.<a class="elsevierStyleCrossRefs" href="#bib0145">7–9</a> Pertussis is a disease that causes epidemics on a cyclical pattern, although since 2010 in Spain there has been a sustained epidemic,<a class="elsevierStyleCrossRef" href="#bib0135">5</a> which was reflected in our study. This phenomenon coincides with the re-emergence of pertussis observed both in the United States and in other European countries due to reasons that are yet unknown; some of the reasons that have been proposed are loss of immunity over time, antigenic drift in circulating strains relative to those used to make the vaccine and lack of vaccination in certain subsets of the population.<a class="elsevierStyleCrossRefs" href="#bib0155">9–13</a> In our region, between 2003 and 2010, the incidence in infants aged less than 1 year who required hospital admission only exceeded 100 cases in years 2003 (103 cases) and 2006 (204.5 cases).<a class="elsevierStyleCrossRef" href="#bib0140">6</a> Since 2010, the annual incidence of cases with hospital admission exceeded 130 per 100000 inhabitants, with peaks of 365.0 and 425.0 cases in 2011 and 2015, respectively. However, in 2016 there was a decrease in incidence that coincided with the introduction of vaccination of pregnant women. This measure should be analysed in the long term to determine whether this trend is sustained, as it could also have been due to the data being collected in an interepidemic period.Comparing incidence data between countries poses significant difficulties due to differences in the case definition, the diagnostic techniques used and reporting systems.<a class="elsevierStyleCrossRefs" href="#bib0120">2,14</a> According to data from the European Centre for Disease Prevention and Control, in 2014 the highest reported age-specific rate corresponded to infants aged less than 1 year, with an incidence of 51.6 cases per 100000 inhabitants in Europe overall. Spain, Lithuania, the Netherlands, Slovenia and Sweden were the countries with the highest incidence rates, with more than 100 cases per 100000 inhabitants in this age group.<a class="elsevierStyleCrossRef" href="#bib0185">15</a> According to several studies, pertussis may be underdiagnosed, so its actual incidence could be higher. Basing the case definition on clinical variables could contribute to underdiagnosis, as such a definition is limited because signs and symptoms vary with age and vaccination status and also because physicians still maintain a low level of suspicion, especially in adolescents and adults. Recently, a research group proposed a diagnostic algorithm based on clinical signs and symptoms by age group.<a class="elsevierStyleCrossRef" href="#bib0190">16</a> According to this algorithm, pertussis should be suspected in infants aged less than 3 months if they present with coughing and coryza, especially in cases where the cough increases in frequency and severity, independently of its duration or whether or not it is paroxysmal, or infants presenting with leucocytosis and lymphocytosis. In our study, most patients presented with cough, accompanied by cold symptoms in 2/3 of cases, and most also had lymphocytosis. We ought to note that pneumonia and apnoea developed mainly in infants aged less than 3 months, as described in previous studies,<a class="elsevierStyleCrossRef" href="#bib0195">17</a> but we found no other differences in other signs and symptoms between the 2 age groups.The population aged less than 1 year is at higher risk of complications. We observed complications in 15.4% of patients, mostly pneumonia. Younger age and unvaccinated status were the most significant factors associated to the development of complications, although none of the patients died. Compared to the preceding period, we found a lower rate of complications (23.4% in the 2003–2007 period) and a lower mortality (6.5% in the 2003–2007 period). Other studies have found a higher rate of complications in this age group.<a class="elsevierStyleCrossRef" href="#bib0195">17</a> Several studies have analysed different variables and have found a higher risk of death or more severe disease in infants aged less than 4 months with low birth weight, hyperleukocytosis (≥100000 leukocytes/μL), who develop pulmonary hypertension or seizures or with unvaccinated status, among others,<a class="elsevierStyleCrossRefs" href="#bib0200">18–20</a> and a high degree of suspicion in these patients would probably improve clinical outcomes.Viruses were detected in a high proportion of patients in whom B. pertussis infection was ruled out. The virus detected most frequently was respiratory syncytial virus, which demonstrates the overlap of signs and symptoms in this subset of the population, a fact that has been described by other authors.<a class="elsevierStyleCrossRefs" href="#bib0215">21,22</a> Furthermore, a viral coinfection was detected in a small proportion of the sample (most commonly by rhinoviruses), which was consistent with previous studies in which rhinoviruses and coronaviruses were most frequently detected in cases of coinfection.<a class="elsevierStyleCrossRef" href="#bib0220">22</a>In conclusion, in recent years there has been an increase in the incidence of pertussis in infants aged less than 1 year in our region associated with decreases in the incidence of complications and in mortality compared to the previous period. Younger age and unvaccinated status were the main risk factors associated with the development of complications. The incidence of pertussis and its complications would probably decrease with vaccination of pregnant women, so it is important that long-term followup studies be conducted to assess the effectiveness of this preventive measure.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1077235" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1023266" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1077236" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1023267" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Methods" ] 7 => array:3 [ "identificador" => "sec0025" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Epidemiology" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical manifestations" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Coinfection with other pathogens" ] ] ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-06-27" "fechaAceptado" => "2017-10-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1023266" "palabras" => array:5 [ 0 => "Bordetella pertussis" 1 => "Whooping cough" 2 => "Incidence rate" 3 => "Coinfection" 4 => "Pneumonia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1023267" "palabras" => array:5 [ 0 => "Bordetella pertussis" 1 => "Tosferina" 2 => "Tasa de incidencia" 3 => "Coinfección" 4 => "Neumonía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveDescribe the epidemiological and clinical pattern of Bordetella pertussis infection (whooping cough) among hospitalised infants less than one year-old in a paediatric hospital in Gran Canaria. Patients and methodsA retrospective review of the patient hospital records was performed, and recording only those with a microbiological diagnosis of pertussis infection detected using polymerase chain reaction, from January 2008 to December 2016. ResultsA total of 110 patients were identified, of which 105 (95.4%) were less than 6 months old, and 59.1% were males. The annual incidence of hospital admissions was estimated between 13.7 and 425.0 cases per 100000 infants <12 months old, with 2 peaks in 2011 and 2015. Household members were the main potential sources of infection. Main clinical features were pertussis cough associated with signs of catarrh, cyanosis, and lymphocytosis. Complications occurred in 15.4% of the patients (mainly pneumonia), but the outcome was favourable in all the cases. A lower age and non-vaccination were associated with an increased risk of developing complications (p<.05). Viral co-infection occurred in 31.6% of infants diagnosed with pertussis. ConclusionsThe incidence of pertussis has increased in the last years in Gran Canaria, with a lower development of complications and mortality rates compared with the previous period. Lower age and non-vaccination status are considered risk factors for developing complications. Vaccination in pregnant women will probably lead to a decline in the incidence in the future, especially in infants younger than 6 months." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoDescribir el patrón epidemiológico y clínico de la infección por Bordetella pertussis (tosferina) en niños menores de un año hospitalizados en un hospital pediátrico de Gran Canaria. Pacientes y métodosSe revisaron retrospectivamente las historias clínicas de los pacientes con diagnóstico microbiológico de infección por B. pertussis mediante reacción en cadena de la polimerasa, de enero de 2008 a diciembre de 2016. ResultadosSe identificaron 110 pacientes, de los cuales 105 (95,4%) fueron menores de 6 meses y el 59,1% eran varones. La incidencia anual de hospitalización se estimó entre 13,7 y 425,0 casos por cada 100.000 lactantes menores de 12 meses, con 2 picos en 2011 y 2015. Los familiares cercanos fueron las principales fuentes de contagio potenciales. Las principales manifestaciones fueron la tos pertusoide asociada con signos catarrales, cianosis y linfocitosis. El 15,4% de los pacientes presentaron complicaciones (principalmente neumonía), pero la evolución fue favorable en todos los casos. La menor edad y la no vacunación se asociaron con un mayor riesgo de desarrollar complicaciones (p<0,05). La coinfección viral ocurrió en el 31,6% de los pacientes diagnosticados de infección por B. pertussis. ConclusionesLa incidencia de infección por B. pertussis ha aumentado en los últimos años en nuestra área, con un menor desarrollo de complicaciones y con tasas de mortalidad inferiores al período anterior. La menor edad y la no vacunación previa se consideran factores de riesgo para el desarrollo de complicaciones. La vacunación en mujeres embarazadas probablemente disminuirá la incidencia en el futuro, sobre todo en niños menores de 6 meses." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Iglesias L, Casabella Pernas A, Hernández Febles M, Colino Gil E, Eisman Maraver A, Pena López MJ. Estudio clínico-epidemiológico de la infección por Bordetella pertussis en la isla de Gran Canaria en el período 2008-2016. An Pediatr (Barc). 2018;89:170–175." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "Previous presentation: This study was presented at the XXI National Congress of the Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (communication No. 300)." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 809 "Ancho" => 1582 "Tamanyo" => 84836 ] ] "descripcion" => array:1 [ "en" => "Annual incidence of laboratory-confirmed pertussis per 100000 infants aged less than 1 year (2008–2016)." ] ] 1 => 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 [ "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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age ≤3 months (%) n=65 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age >3 months (%) n=45 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total (%) n=110 \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="4" align="left" valign="top">Clinical manifestations</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65 (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 (97.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">109 (99.1) \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">Whooping cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 (86.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (71.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88 (80.0) \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">Cold symptoms<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 (66.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73 (66.4) \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">Cyanosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 (53.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (48.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 (51.8) \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">Posttussive vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (30.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (26.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (29.1) \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">Fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (12.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (17.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (14.5) \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">Apnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (10.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (4.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (8.2) \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">Pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (9.1) \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">Tachypnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (4.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (2.7) \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">Polypnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (3.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (1.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="" valign="top" style="border-bottom: 2px solid black"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Laboratory findings<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">n=64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">n=43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">n=107 \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">Lymphocytosis: absolute (>10000/mm3) or relative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 (90.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 (95.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">99 (92.5) \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">Leucocytosis (>17500/mm3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (46.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 (34.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 (42.1) \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">Thrombocytosis (>450000/mm3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 (67.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (55.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67 (62.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1838776.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Upper respiratory tract disease: rhinorrhoea, coryza, sneezing or lacrimation." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Data from 107 patients (97.3%)." ] ] ] "descripcion" => array:1 [ "en" => "Clinical manifestations and laboratory findings in the 110 patients with infection by B. pertussis." ] ] 2 => 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" => "AZM, azithromycin; F, female; IV, intravenous; M, male; MV, mechanical ventilation; PN, parenteral nutrition; RLE, right lower extremity; RSV, respiratory syncytial 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">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age (days)/sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vaccination \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Leucocytes per×1000/mm3<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Coinfection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ICU admission \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \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 " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">103.0 \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">Pneumonia, hyperleukocytosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, MV, sedation/muscle relaxation, exchange transfusion, inhaled adrenaline, dexamethasone iv \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.1 \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">Pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, MV, sedation/muscle relaxation, PN \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.0 \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">Pneumonia, ischaemic necrosis of RLE requiring amputation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, MV, sedation/muscle relaxation, PN \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.7 \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">Pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, MV, sedation/muscle relaxation, PN \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46.3 \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">Pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MV, sedation/muscle relaxation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37.5 \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">Pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, MV, sedation/muscle relaxation, PN \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54.7 \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">Pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, MV, sedation/muscle relaxation, PN \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RSV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pneumonia, convulsive seizures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, clonazepam \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67.1 \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">Pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 10 days, oxygen, PN, enoxaparin, Inhaled adrenaline \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data \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">Pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Coxsackievirus B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Apnoea secondary to coughing fits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, upright position and oxygen during fits \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.3 \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">Apnoea secondary to coughing fits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, upright position and oxygen during fits \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rhinovirus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Apnoea secondary to coughing fits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, upright position and oxygen during fits \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.7 \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">Apnoea secondary to coughing fits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, upright position and oxygen during fits \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.5 \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">Apnoea secondary to coughing fits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, upright position and oxygen during fits \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21.0 \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">Apnoea secondary to coughing fits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, upright position and oxygen during fits \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">140/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.1 \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">Apnoea (1 episode before admission) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AZM 5 days, upright position and oxygen during fits \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1838778.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "Peak leucocyte count during monitoring." ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of patients that developed complications." ] ] 3 => 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" => "NS, not significant." "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">Risk factor \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infants with complications (n=17) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infants without complications (n=93) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \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">Age in days, mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52.6±29.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88±53.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.003 \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">Preterm birth, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (11.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (15.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Vaccination not initiated, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (82.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42 (45.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.005 \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">Coinfection, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (17.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 (16.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Leucocytes/μL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24125±14097.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16823.3±8701.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1838777.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Risk factors in patients that did and did not develop complications." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0115" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "pii=20875" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Increase of pertussis incidence in 2010 to 2012 after 12 years of low circulation in Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "V. 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Original Article

Clinical-epidemiological study of Bordetella pertussis infection in the Gran Canaria island in the period, 2008–2016

Estudio clínico-epidemiológico de la infección por Bordetella pertussis en la isla de Gran Canaria en el período 2008-2016

Laura Iglesiasa,

Corresponding author

laura.igll@hotmail.com

Corresponding author.

, Antonio Casabella Pernasa, Melisa Hernández Feblesa, Elena Colino Gilb, Alicia Eisman Maravera, María José Pena Lópeza

a Servicio de Microbiología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain

b Servicio de Pediatría, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Spain

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        "titulo" => "Estudio cl&#237;nico-epidemiol&#243;gico de la infecci&#243;n por <span class="elsevierStyleItalic">Bordetella pertussis</span> en la isla de Gran Canaria en el per&#237;odo 2008-2016"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Annual incidence of laboratory-confirmed pertussis per 100<span class="elsevierStyleHsp" style=""></span>000 infants aged less than 1 year &#40;2008&#8211;2016&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pertussis is a vaccine-preventable infectious disease caused by <span class="elsevierStyleItalic">Bordetella pertussis</span>&#46; In recent years&#44; there has been evidence of an increased incidence in many countries with a high vaccination coverage&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;2</span></a> Variations in published incidence rates may be due to differences in case reporting systems and access to diagnostic tests&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#8211;4</span></a> but the highest rates are always reported in infants aged less than 1 year&#44; who also experience the most complications and highest mortality&#46; The Canary Islands is one of the autonomous communities in Spain with the highest rates of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> In the 2003&#8211;2007 period&#44; we performed a study where we found a high incidence of complications and mortality in this age group&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a> For this reason&#44; since 2015&#44; vaccination of pregnant women was introduced in our autonomous community&#46; In order to determine the subsequent trends of infection&#44; we have conducted a clinical-epidemiological study of all the cases diagnosed in infants aged less than 1 year that visited the emergency department of the only public paediatric hospital in the island of Gran Canaria between 2008 and 2016&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0010" class="elsevierStylePara elsevierViewall">The study included the 1&#44;040 patients aged less than 1 year that visited the emergency department of the Hospital Materno Infantil de Gran Canaria &#40;which serves an average of 6&#44;770 infants aged less than 1 year&#41; with a clinical presentation that required ruling out <span class="elsevierStyleItalic">B&#46; pertussis</span> between January 2008 and December 2016&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">All patients underwent testing for detection of <span class="elsevierStyleItalic">B&#46; pertussis</span> by means of polymerase chain reaction &#40;PCR&#41; &#40;LightMix Kit Bordetella pertussis&#47;parapertussis or Diagenode Bordetella pertussis&#47;parapertussis&#41; in samples of nasopharyngeal exudate obtained with a flexible swab&#46; Viral detection tests were also performed 581patients &#40;55&#46;9&#37;&#41; in nasopharyngeal aspirate samples&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We performed a retrospective review of the health records of patients who tested positive for <span class="elsevierStyleItalic">B&#46; pertussis</span>&#44; collecting data on demographic variables&#44; vaccination history&#44; probably source of infection &#40;contacts with clinical features compatible with pertussis&#41;&#44; symptoms&#44; laboratory data and treatment&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the statistical analysis&#44; we used the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test to compare quantitative variables and the chi square test to compare proportions&#46; We defined statistical significance as a <span class="elsevierStyleItalic">p</span>-value of less than &#46;05&#46; The study was approved by the local bioethics and research committee&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Epidemiology</span><p id="par0030" class="elsevierStylePara elsevierViewall">Infection by <span class="elsevierStyleItalic">B&#46; pertussis</span> was detected in 110 patients &#40;10&#46;6&#37;&#41;&#46; A different pathogen was identified in 269 patients &#40;25&#46;7&#37;&#41;&#58; respiratory syncytial virus in 175&#44; rhinovirus in 33&#44; parainfluenzavirus 3 in 32&#44; metapneumovirus in 7&#44; cytomegalovirus in 5&#44; influenza A in 5&#44; influenza B in 4&#44; enterovirus in 3&#44; parainfluenzavirus 1 in 2&#44; parainfluenzavirus 2 in 2&#44; and coxsackievirus B in 1&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Of the 110 infants with infection by <span class="elsevierStyleItalic">B&#46; pertussis</span>&#44; 65 were male &#40;59&#46;1&#37;&#41;&#46; The mean age was 83&#46;3 days &#40;range&#44; 14&#8211;287 days&#41;&#44; and 105 &#40;95&#46;4&#37;&#41; were aged less than 6 months&#46; Eleven had been born preterm &#40;10&#46;0&#37;&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the annual incidence of pertussis cases per 100<span class="elsevierStyleHsp" style=""></span>000 infants aged less than 1 year that sought care in the hospital&#46; The annual incidence ranged between 13&#46;7 cases in 2009 and 425&#46;0 cases in 2015&#44; with 2 peaks in years 2011 and 2015&#46; Since 2010&#44; the year with the lowest incidence was 2016&#46; When it came to the seasonal distribution&#44; 33&#46;6&#37; of cases occurred in summer&#44; 29&#46;1&#37; in spring&#44; 19&#46;1&#37; in winter and 18&#46;2&#37; in autumn&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">As for the vaccination status of the patients&#44; 56 infants &#40;50&#46;9&#37;&#41; had not started to receive routine vaccinations&#44; 47 &#40;42&#46;7&#37;&#41; had received 1 dose&#44; 5 &#40;4&#46;5&#37;&#41; 2 doses and 2 &#40;1&#46;8&#37;&#41; 3 doses&#46; Only 1 child was incorrectly vaccinated for age&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A probable source of infection was documented in 45 patients &#40;40&#46;9&#37;&#41;&#44; corresponding to household members in 44 cases &#40;97&#46;8&#37;&#41; and nosocomial infection in 1&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Seventeen infants with pertussis were born after the introduction of vaccination of pregnant women&#59; in 5 of these infants &#40;29&#46;4&#37;&#41; the mother had received the vaccine in the third trimester of pregnancy &#40;one at 28 weeks&#44; one at 31 weeks&#44; timing not documented in the remaining 3&#41;&#46; The mean age of these 5 infants was 2&#46;8 months &#40;range&#44; 0&#8211;5 months&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Clinical manifestations</span><p id="par0060" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the clinical manifestations and abnormal laboratory findings in 110 patients&#46; The characteristic clinical presentation consisted of whooping cough accompanied by cold symptoms&#44; cyanosis and lymphocytosis&#46; The only difference in clinical characteristics between older infants and infants aged less than 3 months was the development of pneumonia&#44; which only occurred in those aged less than 3 months &#40;<span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; The mean time elapsed from onset of symptoms to the emergency department visit was 9&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;9 days &#40;range&#44; 1&#8211;28 days&#41;&#46; A total of 107 patients were admitted to hospital &#40;97&#46;3&#37;&#41; for a mean length of stay of 10&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;3 days &#40;range&#44; 0&#8211;45 days&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Complications developed in 17 patients &#40;15&#46;4&#37;&#41;&#58; 10 cases of pneumonia and 7 of apnoea&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents the characteristics of the infants that developed complications&#58; 82&#46;3&#37; had not started vaccination&#44; and the rest had only received 1 dose&#46; Nine infants with pneumonia were admitted to the intensive care unit &#40;ICU&#41;&#46; One girl aged 42 days &#40;case 1&#41; that was admitted to the ICU had originally presented with a leucocyte count of 27<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&#44; but at 13 days from onset had developed hyperleukocytosis &#40;103<span class="elsevierStyleHsp" style=""></span>000 leucocytes&#47;&#956;L&#41;&#44; so she underwent a double volume exchange transfusion&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the differences between infants that developed complications and infants that did not&#46; Their comparison reveals that infants who developed complications were younger and that a higher proportion of patients in this group had not initiated routine vaccinations&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">All patients received treatment from the time of admission with azithromycin &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; for 5 days &#40;except 1 patient treated for 10 days&#41;&#44; with favourable outcomes&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Coinfection with other pathogens</span><p id="par0075" class="elsevierStylePara elsevierViewall">Fifty-seven patients &#40;51&#46;8&#37;&#41; with infection <span class="elsevierStyleItalic">B&#46; pertussis</span> underwent viral detection tests&#44; which revealed in 18 &#40;31&#46;6&#37;&#41;&#58; by rhinovirus in 9&#44; parainfluenzavirus 3 in 3&#44; respiratory syncytial virus in 2&#44; adenovirus in 1&#44; influenza C in 1&#44; cytomegalovirus in 1 and coxsackievirus B in 1&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Despite the high vaccination coverage in the paediatric population&#44; pertussis continues to be a significant health problem that recently led to the introduction of vaccination of pregnant women in the autonomous community of the Canary Islands with the intent to protect infants&#44; the most vulnerable subset&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">7&#8211;9</span></a> Pertussis is a disease that causes epidemics on a cyclical pattern&#44; although since 2010 in Spain there has been a sustained epidemic&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> which was reflected in our study&#46; This phenomenon coincides with the re-emergence of pertussis observed both in the United States and in other European countries due to reasons that are yet unknown&#59; some of the reasons that have been proposed are loss of immunity over time&#44; antigenic drift in circulating strains relative to those used to make the vaccine and lack of vaccination in certain subsets of the population&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">9&#8211;13</span></a> In our region&#44; between 2003 and 2010&#44; the incidence in infants aged less than 1 year who required hospital admission only exceeded 100 cases in years 2003 &#40;103 cases&#41; and 2006 &#40;204&#46;5 cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a> Since 2010&#44; the annual incidence of cases with hospital admission exceeded 130 per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#44; with peaks of 365&#46;0 and 425&#46;0 cases in 2011 and 2015&#44; respectively&#46; However&#44; in 2016 there was a decrease in incidence that coincided with the introduction of vaccination of pregnant women&#46; This measure should be analysed in the long term to determine whether this trend is sustained&#44; as it could also have been due to the data being collected in an interepidemic period&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Comparing incidence data between countries poses significant difficulties due to differences in the case definition&#44; the diagnostic techniques used and reporting systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;14</span></a> According to data from the European Centre for Disease Prevention and Control&#44; in 2014 the highest reported age-specific rate corresponded to infants aged less than 1 year&#44; with an incidence of 51&#46;6 cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in Europe overall&#46; Spain&#44; Lithuania&#44; the Netherlands&#44; Slovenia and Sweden were the countries with the highest incidence rates&#44; with more than 100 cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in this age group&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> According to several studies&#44; pertussis may be underdiagnosed&#44; so its actual incidence could be higher&#46; Basing the case definition on clinical variables could contribute to underdiagnosis&#44; as such a definition is limited because signs and symptoms vary with age and vaccination status and also because physicians still maintain a low level of suspicion&#44; especially in adolescents and adults&#46; Recently&#44; a research group proposed a diagnostic algorithm based on clinical signs and symptoms by age group&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">16</span></a> According to this algorithm&#44; pertussis should be suspected in infants aged less than 3 months if they present with coughing and coryza&#44; especially in cases where the cough increases in frequency and severity&#44; independently of its duration or whether or not it is paroxysmal&#44; or infants presenting with leucocytosis and lymphocytosis&#46; In our study&#44; most patients presented with cough&#44; accompanied by cold symptoms in 2&#47;3 of cases&#44; and most also had lymphocytosis&#46; We ought to note that pneumonia and apnoea developed mainly in infants aged less than 3 months&#44; as described in previous studies&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">17</span></a> but we found no other differences in other signs and symptoms between the 2 age groups&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The population aged less than 1 year is at higher risk of complications&#46; We observed complications in 15&#46;4&#37; of patients&#44; mostly pneumonia&#46; Younger age and unvaccinated status were the most significant factors associated to the development of complications&#44; although none of the patients died&#46; Compared to the preceding period&#44; we found a lower rate of complications &#40;23&#46;4&#37; in the 2003&#8211;2007 period&#41; and a lower mortality &#40;6&#46;5&#37; in the 2003&#8211;2007 period&#41;&#46; Other studies have found a higher rate of complications in this age group&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">17</span></a> Several studies have analysed different variables and have found a higher risk of death or more severe disease in infants aged less than 4 months with low birth weight&#44; hyperleukocytosis &#40;&#8805;100<span class="elsevierStyleHsp" style=""></span>000 leukocytes&#47;&#956;L&#41;&#44; who develop pulmonary hypertension or seizures or with unvaccinated status&#44; among others&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">18&#8211;20</span></a> and a high degree of suspicion in these patients would probably improve clinical outcomes&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Viruses were detected in a high proportion of patients in whom <span class="elsevierStyleItalic">B&#46; pertussis</span> infection was ruled out&#46; The virus detected most frequently was respiratory syncytial virus&#44; which demonstrates the overlap of signs and symptoms in this subset of the population&#44; a fact that has been described by other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">21&#44;22</span></a> Furthermore&#44; a viral coinfection was detected in a small proportion of the sample &#40;most commonly by rhinoviruses&#41;&#44; which was consistent with previous studies in which rhinoviruses and coronaviruses were most frequently detected in cases of coinfection&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion&#44; in recent years there has been an increase in the incidence of pertussis in infants aged less than 1 year in our region associated with decreases in the incidence of complications and in mortality compared to the previous period&#46; Younger age and unvaccinated status were the main risk factors associated with the development of complications&#46; The incidence of pertussis and its complications would probably decrease with vaccination of pregnant women&#44; so it is important that long-term followup studies be conducted to assess the effectiveness of this preventive measure&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Describe the epidemiological and clinical pattern of <span class="elsevierStyleItalic">Bordetella pertussis</span> infection &#40;whooping cough&#41; among hospitalised infants less than one year-old in a paediatric hospital in Gran Canaria&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective review of the patient hospital records was performed&#44; and recording only those with a microbiological diagnosis of pertussis infection detected using polymerase chain reaction&#44; from January 2008 to December 2016&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 110 patients were identified&#44; of which 105 &#40;95&#46;4&#37;&#41; were less than 6 months old&#44; and 59&#46;1&#37; were males&#46; The annual incidence of hospital admissions was estimated between 13&#46;7 and 425&#46;0 cases per 100<span class="elsevierStyleHsp" style=""></span>000 infants &#60;12 months old&#44; with 2 peaks in 2011 and 2015&#46; Household members were the main potential sources of infection&#46; Main clinical features were pertussis cough associated with signs of catarrh&#44; cyanosis&#44; and lymphocytosis&#46; Complications occurred in 15&#46;4&#37; of the patients &#40;mainly pneumonia&#41;&#44; but the outcome was favourable in all the cases&#46; A lower age and non-vaccination were associated with an increased risk of developing complications &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; Viral co-infection occurred in 31&#46;6&#37; of infants diagnosed with pertussis&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The incidence of pertussis has increased in the last years in Gran Canaria&#44; with a lower development of complications and mortality rates compared with the previous period&#46; Lower age and non-vaccination status are considered risk factors for developing complications&#46; Vaccination in pregnant women will probably lead to a decline in the incidence in the future&#44; especially in infants younger than 6 months&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir el patr&#243;n epidemiol&#243;gico y cl&#237;nico de la infecci&#243;n por <span class="elsevierStyleItalic">Bordetella pertussis</span> &#40;tosferina&#41; en ni&#241;os menores de un a&#241;o hospitalizados en un hospital pedi&#225;trico de Gran Canaria&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se revisaron retrospectivamente las historias cl&#237;nicas de los pacientes con diagn&#243;stico microbiol&#243;gico de infecci&#243;n por <span class="elsevierStyleItalic">B&#46; pertussis</span> mediante reacci&#243;n en cadena de la polimerasa&#44; de enero de 2008 a diciembre de 2016&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se identificaron 110 pacientes&#44; de los cuales 105 &#40;95&#44;4&#37;&#41; fueron menores de 6 meses y el 59&#44;1&#37; eran varones&#46; La incidencia anual de hospitalizaci&#243;n se estim&#243; entre 13&#44;7 y 425&#44;0 casos por cada 100&#46;000 lactantes menores de 12 meses&#44; con 2 picos en 2011 y 2015&#46; Los familiares cercanos fueron las principales fuentes de contagio potenciales&#46; Las principales manifestaciones fueron la tos pertusoide asociada con signos catarrales&#44; cianosis y linfocitosis&#46; El 15&#44;4&#37; de los pacientes presentaron complicaciones &#40;principalmente neumon&#237;a&#41;&#44; pero la evoluci&#243;n fue favorable en todos los casos&#46; La menor edad y la no vacunaci&#243;n se asociaron con un mayor riesgo de desarrollar complicaciones &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; La coinfecci&#243;n viral ocurri&#243; en el 31&#44;6&#37; de los pacientes diagnosticados de infecci&#243;n por <span class="elsevierStyleItalic">B&#46; pertussis</span>&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La incidencia de infecci&#243;n por <span class="elsevierStyleItalic">B&#46; pertussis</span> ha aumentado en los &#250;ltimos a&#241;os en nuestra &#225;rea&#44; con un menor desarrollo de complicaciones y con tasas de mortalidad inferiores al per&#237;odo anterior&#46; La menor edad y la no vacunaci&#243;n previa se consideran factores de riesgo para el desarrollo de complicaciones&#46; La vacunaci&#243;n en mujeres embarazadas probablemente disminuir&#225; la incidencia en el futuro&#44; sobre todo en ni&#241;os menores de 6 meses&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Iglesias L&#44; Casabella Pernas A&#44; Hern&#225;ndez Febles M&#44; Colino Gil E&#44; Eisman Maraver A&#44; Pena L&#243;pez MJ&#46; Estudio cl&#237;nico-epidemiol&#243;gico de la infecci&#243;n por <span class="elsevierStyleItalic">Bordetella pertussis</span> en la isla de Gran Canaria en el per&#237;odo 2008-2016&#46; An Pediatr &#40;Barc&#41;&#46; 2018&#59;89&#58;170&#8211;175&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Previous presentation&#58; This study was presented at the <span class="elsevierStyleSmallCaps">XXI</span> National Congress of the Sociedad Espa&#241;ola de Enfermedades Infecciosas y Microbiolog&#237;a Cl&#237;nica &#40;communication No&#46; 300&#41;&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 809
            "Ancho" => 1582
            "Tamanyo" => 84836
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Annual incidence of laboratory-confirmed pertussis per 100<span class="elsevierStyleHsp" style=""></span>000 infants aged less than 1 year &#40;2008&#8211;2016&#41;&#46;</p>"
        ]
      ]
      1 => 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 [
          "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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age &#8804;3 months &#40;&#37;&#41;<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age &#62;3 months &#40;&#37;&#41;<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total &#40;&#37;&#41;<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>110&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="4" align="left" valign="top"><span class="elsevierStyleItalic">Clinical manifestations</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>Cough&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44 &#40;97&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">109 &#40;99&#46;1&#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>Whooping cough&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56 &#40;86&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;71&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88 &#40;80&#46;0&#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>Cold symptoms<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43 &#40;66&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73 &#40;66&#46;4&#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>Cyanosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35 &#40;53&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;48&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57 &#40;51&#46;8&#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>Posttussive vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;30&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;26&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;29&#46;1&#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>Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;12&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;17&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;14&#46;5&#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>Apnoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;10&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;4&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;8&#46;2&#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>Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;15&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;9&#46;1&#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>Tachypnoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;4&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;2&#46;7&#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>Polypnoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;3&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;1&#46;8&#41;&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="4" align="" valign="top" style="border-bottom: 2px solid black"><span class="elsevierStyleVsp" style="height:0.5px"></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="elsevierStyleItalic">Laboratory findings</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>64&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="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>43&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="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>107&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>Lymphocytosis&#58; absolute &#40;&#62;10<span class="elsevierStyleHsp" style=""></span>000&#47;mm<span class="elsevierStyleSup">3</span>&#41; or relative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58 &#40;90&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41 &#40;95&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">99 &#40;92&#46;5&#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>Leucocytosis &#40;&#62;17<span class="elsevierStyleHsp" style=""></span>500&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;46&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;34&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45 &#40;42&#46;1&#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>Thrombocytosis &#40;&#62;450<span class="elsevierStyleHsp" style=""></span>000&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43 &#40;67&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;55&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67 &#40;62&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1838776.png"
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          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Upper respiratory tract disease&#58; rhinorrhoea&#44; coryza&#44; sneezing or lacrimation&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Data from 107 patients &#40;97&#46;3&#37;&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Clinical manifestations and laboratory findings in the 110 patients with infection by <span class="elsevierStyleItalic">B&#46; pertussis</span>&#46;</p>"
        ]
      ]
      2 => 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" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AZM&#44; azithromycin&#59; F&#44; female&#59; IV&#44; intravenous&#59; M&#44; male&#59; MV&#44; mechanical ventilation&#59; PN&#44; parenteral nutrition&#59; RLE&#44; right lower extremity&#59; RSV&#44; respiratory syncytial 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">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age &#40;days&#41;&#47;sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vaccination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Leucocytes per<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1000&#47;mm<span class="elsevierStyleSup">3</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Coinfection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ICU admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&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  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">103&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&#44; hyperleukocytosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; MV&#44; sedation&#47;muscle relaxation&#44; exchange transfusion&#44; inhaled adrenaline&#44; dexamethasone iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#47;<span class="elsevierStyleSmallCaps">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; MV&#44; sedation&#47;muscle relaxation&#44; PN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#47;<span class="elsevierStyleSmallCaps">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&#44; ischaemic necrosis of RLE requiring amputation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; MV&#44; sedation&#47;muscle relaxation&#44; PN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#47;<span class="elsevierStyleSmallCaps">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; MV&#44; sedation&#47;muscle relaxation&#44; PN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MV&#44; sedation&#47;muscle relaxation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&#47;<span class="elsevierStyleSmallCaps">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; MV&#44; sedation&#47;muscle relaxation&#44; PN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#47;<span class="elsevierStyleSmallCaps">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; MV&#44; sedation&#47;muscle relaxation&#44; PN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#46;0&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="elsevierStyleItalic">RSV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&#44; convulsive seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; clonazepam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 10 days&#44; oxygen&#44; PN&#44; enoxaparin&#44;<br>Inhaled adrenaline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#47;<span class="elsevierStyleSmallCaps">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;3&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="elsevierStyleItalic">Coxsackievirus B</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Apnoea secondary to coughing fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; upright position and oxygen during fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Apnoea secondary to coughing fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; upright position and oxygen during fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#47;<span class="elsevierStyleSmallCaps">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;2&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="elsevierStyleItalic">Rhinovirus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Apnoea secondary to coughing fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; upright position and oxygen during fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Apnoea secondary to coughing fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; upright position and oxygen during fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#47;<span class="elsevierStyleSmallCaps">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Apnoea secondary to coughing fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AZM 5 days&#44; upright position and oxygen during fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Apnoea secondary to coughing fits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&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">15 &#40;16&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2017.10.007

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Year/Month	Html	Pdf	Total

2024 November	9	10	19
2024 October	48	40	88
2024 September	56	32	88
2024 August	61	64	125
2024 July	56	31	87
2024 June	78	44	122
2024 May	68	31	99
2024 April	55	37	92
2024 March	54	34	88
2024 February	39	22	61
2024 January	52	23	75
2023 December	32	25	57
2023 November	44	26	70
2023 October	41	22	63
2023 September	26	22	48
2023 August	33	12	45
2023 July	42	25	67
2023 June	45	28	73
2023 May	42	19	61
2023 April	45	19	64
2023 March	51	24	75
2023 February	53	18	71
2023 January	18	21	39
2022 December	56	35	91
2022 November	54	26	80
2022 October	72	38	110
2022 September	44	20	64
2022 August	37	49	86
2022 July	40	40	80
2022 June	31	31	62
2022 May	42	42	84
2022 April	49	29	78
2022 March	76	55	131
2022 February	42	33	75
2022 January	34	32	66
2021 December	38	38	76
2021 November	66	38	104
2021 October	108	65	173
2021 September	27	39	66
2021 August	27	45	72
2021 July	20	30	50
2021 June	39	46	85
2021 May	56	45	101
2021 April	148	71	219
2021 March	223	36	259
2021 February	52	20	72
2021 January	51	20	71
2020 December	54	17	71
2020 November	48	18	66
2020 October	35	21	56
2020 September	63	22	85
2020 August	46	6	52
2020 July	46	24	70
2020 June	52	11	63
2020 May	56	22	78
2020 April	26	15	41
2020 March	43	14	57
2020 February	68	7	75
2020 January	51	9	60
2019 December	85	24	109
2019 November	29	8	37
2019 October	49	14	63
2019 September	47	16	63
2019 August	100	22	122
2019 July	43	27	70
2019 June	32	22	54
2019 May	61	19	80
2019 April	81	21	102
2019 March	38	19	57
2019 February	51	13	64
2019 January	33	21	54
2018 December	45	27	72
2018 November	101	30	131
2018 October	112	18	130
2018 September	149	29	178
2018 August	0	2	2
2018 July	0	2	2

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