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y en 2006 empez&#243; a operar un sistema de vigilancia centinela de esta enfermedad<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a>&#46; Actualmente&#44; y conforme a los est&#225;ndares normativos&#44; la vacunaci&#243;n contra la gripe se ofrece de forma gratuita a adolescentes y adultos &#40;de 20 a 59 a&#241;os de edad&#41; con factores de riesgo conocidos &#40;por ejemplo&#44; asma no controlada&#44; paciente con VIH&#44; c&#225;ncer&#44; entre otros&#41;&#44; en todos los adultos de 60 a&#241;os o mayores&#44; mujeres embarazadas y sanitarios<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Durante el brote de 2009 de virus de influenza AH1N1 &#40;H1N1pdm09&#41;&#44; M&#233;xico experiment&#243; tres oleadas de gripe &#40;en primavera&#44; verano y oto&#241;o&#41; y una cuarta oleada que tuvo lugar en el invierno de 2011-2012<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">6-8</span></a>&#46; En comparaci&#243;n con otros pa&#237;ses&#44; el exceso de mortalidad observada en M&#233;xico debido al H1N1pdm09 parec&#237;a ser particularmente alta<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La evaluaci&#243;n de los factores de riesgo asociado con el riesgo de fallecer por este virus puede ser &#250;til a la hora de valorar la eficacia de los esfuerzos en pol&#237;ticas de salud p&#250;blica centrados en la reducci&#243;n de la carga de gripe&#44; particularmente cuando se analizan los factores prevenibles<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">10</span></a>&#46; El objetivo de este estudio fue identificar los factores asociados a riesgo de muerte en pacientes adolescentes y adultos hospitalizados con gripe confirmada mediante laboratorio en M&#233;xico durante dos temporadas consecutivas de 2018 a 2020&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0025" class="elsevierStylePara elsevierViewall">Llevamos a cabo un estudio retrospectivo de cohorte desde diciembre del 2019 a marzo del 2020&#46; Se identificaron sujetos potencialmente elegibles &#40;casos de infecci&#243;n por gripe no ambulatorios y confirmados por laboratorio mediante reacci&#243;n cuantitativa en cadena de la polimerasa de transcripci&#243;n inversa &#91;RT-qPCR&#93;&#41; a partir de los registros nominales de un sistema normativo nacional en l&#237;nea &#40;Sistema Online de Notificaci&#243;n para la Vigilancia Epidemiol&#243;gica de la Influenza&#59; acr&#243;nimo en espa&#241;ol SINOLAVE&#41;&#44; perteneciente al Instituto Mexicano del Seguro Social &#40;IMSS&#41;&#46; Seg&#250;n los est&#225;ndares internacionales&#44; los casos sospechosos de infecci&#243;n por gripe en M&#233;xico se registran primero como enfermedad similar a la influenza &#40;ILI&#41; o infecci&#243;n respiratoria aguda grave&#44; seg&#250;n corresponda<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">11&#44;12</span></a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Poblaci&#243;n de estudio</span><p id="par0030" class="elsevierStylePara elsevierViewall">Se seleccionaron individuos de 15 a&#241;os de edad o mayores&#44; con inicio de s&#237;ntomas desde marzo del 2018 hasta febrero del 2020&#46; Se excluyeron los pacientes sin datos de alta hospitalaria&#44; as&#237; como aquellos con datos cl&#237;nicos o epidemiol&#243;gicos carentes de inter&#233;s y pacientes cuya muerte tuvo lugar &#62;&#160;30 d&#237;as naturales desde el ingreso en el hospital&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Recogida de datos</span><p id="par0035" class="elsevierStylePara elsevierViewall">La recopilaci&#243;n de datos a partir del SINOLAVE incluy&#243; las caracter&#237;sticas demogr&#225;ficas &#40;sexo&#44; edad&#44; etnia ind&#237;gena&#41;&#44; consumo de tabaco &#40;en alguna ocasi&#243;n&#41;&#44; antecedentes personales de enfermedades transmisibles &#40;infecci&#243;n por VIH&#41; y enfermedades no transmisibles &#40;obesidad&#44; hipertensi&#243;n arterial&#44; diabetes tipo 2&#44; asma&#44; enfermedad renal cr&#243;nica&#44; inmunosupresi&#243;n&#44; enfermedad pulmonar obstructiva cr&#243;nica o enfermedad cardiovascular&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Tambi&#233;n se extrajeron de la base de datos utilizada otros datos cl&#237;nicos o epidemiol&#243;gicos&#58; vacunaci&#243;n frente a gripe en la misma estaci&#243;n del inicio de la enfermedad aguda &#40;s&#237;&#47;no&#41;&#44; subtipo de gripe identificado&#44; fechas &#40;inicio de la enfermedad&#44; ingreso y alta hospitalaria&#44; inicio del uso de medicamentos antivirales&#41; y empleo de soporte de ventilaci&#243;n mec&#225;nica durante la estancia hospitalaria o ingreso en la unidad de cuidados intensivos &#40;UCI&#41;&#46; La fuente principal de datos del sistema de vigilancia empleado fueron los registros m&#233;dicos y los certificados de defunci&#243;n&#44; cuando correspondieron&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultado</span><p id="par0045" class="elsevierStylePara elsevierViewall">La letalidad hospitalaria en los 30 primeros d&#237;as desde el ingreso por infecci&#243;n de gripe confirmada en el laboratorio fue el resultado principal en el resultado binario que inclu&#237;a la muerte por cualquier causa &#40;s&#237;&#47;no&#41;&#46; Se evalu&#243; conforme a los datos del sistema de vigilancia empleado y los certificados de defunci&#243;n fueron las principales fuentes&#46; Los adultos registrados con &#171;mejor&#237;a cl&#237;nica&#187; registrados como causa de alta hospitalaria se clasificaron como negativos al fatal desenlace&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">M&#233;todos de laboratorio</span><p id="par0050" class="elsevierStylePara elsevierViewall">Los an&#225;lisis RT-qPCR se realizaron sobre espec&#237;menes cl&#237;nicos &#40;hisopo nasofar&#237;ngeo o nasal profundo&#41; en cualquiera de los cuatro laboratorios regionales especializados integrados en la red IMSS de vigilancia epidemiol&#243;gica&#46; Dichos laboratorios reciben las muestras procedentes de todo el pa&#237;s y est&#225;n localizados en los estados de Nuevo Le&#243;n &#40;Noreste&#41;&#44; Jalisco &#40;Centro-Oeste&#41;&#44; Yucat&#225;n &#40;Sur&#41; y Ciudad de M&#233;xico &#40;Regi&#243;n Centro-Este&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">El procedimiento anal&#237;tico de confirmaci&#243;n de gripe &#40;AH1Npdm09&#44; AH1N1&#44; AH3N2 e influenza B&#41; se realiz&#243; siguiendo los est&#225;ndares internacionales<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">13</span></a>&#46; Se us&#243; el SuperScript&#174; <span class="elsevierStyleSmallCaps">iii</span> Platinum&#174; One-step RT-qPCR System&#46; Con anterioridad se hab&#237;a publicado una descripci&#243;n detallada de los m&#233;todos utilizados en la red IMSS<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">14</span></a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">An&#225;lisis estad&#237;stico</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se calcularon estad&#237;sticas resumidas y se fij&#243; el nivel de significaci&#243;n en el 5&#37;&#46; Para valorar la asociaci&#243;n entre la exposici&#243;n al riesgo analizado y el riesgo de muerte en el hospital en los casos confirmados por el laboratorio se usaron los riesgos relativos &#40;RR&#41; y los intervalos de confianza &#40;IC&#41; del 95&#37;&#44; calculados mediante modelos de regresi&#243;n lineal generalizados&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Consideraciones &#233;ticas</span><p id="par0065" class="elsevierStylePara elsevierViewall">Este estudio fue aprobado por el Comit&#233; de &#201;tica e Investigaci&#243;n en Salud local &#40;601&#41; del IMSS&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Resultados</span><p id="par0070" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> se muestra el perfil del estudio y los datos de los 3&#46;422 individuos que se analizaron&#46; La letalidad hospitalaria total fue del 18&#44;1&#37; y fue m&#225;s elevada en pacientes de mayor edad &#40;15-35 a&#241;os&#44; 5&#44;7&#37;&#59; 36-55 a&#241;os&#44; 20&#37;&#44; 56 a&#241;os o mayores&#44; 52&#44;5&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> muestra las caracter&#237;sticas del estudio para las variables seleccionadas&#46; La mayor&#237;a de los participantes fueron mujeres &#40;56&#44;4&#37;&#41; y su media de edad &#40;&#177; la desviaci&#243;n est&#225;ndar&#41; fue de 48&#44;2&#160;&#177;&#160;18&#44;3 a&#241;os&#46; Casi dos tercios &#40;64&#44;7&#37;&#41; de los casos de gripe confirmados por laboratorio tuvieron lugar en invierno &#40;hemisferio Norte&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">La frecuencia de vacunaci&#243;n contra la gripe durante la misma temporada de influenza fue del 14&#44;1 y del 8&#44;3&#37;&#44; en mujeres y hombres&#44; respectivamente &#40;total&#44; 11&#44;5&#37;&#41;&#46; Tambi&#233;n fue baja la prevalencia de la inmunizaci&#243;n neumoc&#243;cica en los participantes mayores de 65 a&#241;os &#40;1&#44;5&#37;&#41; y no se observaron diferencias relacionadas con el sexo &#40;hombres&#44; 0&#44;5&#37;&#59; mujeres 2&#44;3&#37;&#59; p&#160;&#61;&#160;0&#44;124&#41;&#46; La estancia media hospitalaria fue de 7&#44;1&#160;&#177;&#160;8&#44;5 d&#237;as&#46; Las enfermedades cr&#243;nicas analizadas m&#225;s frecuentes fueron&#58; hipertensi&#243;n arterial&#44; diabetes tipo 2 y obesidad&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Al comparar los casos fatales y no fatales de influenza &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; los pacientes que principalmente no se recuperaron durante los 30 primeros d&#237;as tras el ingreso hospitalario fueron hombres &#40;58&#44;8 vs&#46; 40&#44;3&#37;&#44; p&#160;&#60;&#160;0&#44;001&#41;&#44; de 56 a&#241;os o mayores &#40;52&#44;5 vs&#46; 31&#44;6&#37;&#44; p&#160;&#60;&#160;0&#44;001&#41; y no vacunados contra la gripe &#40;95&#44;3&#37; vs&#46; 86&#44;9&#37;&#44; p&#160;&#60;&#160;0&#44;001&#41;&#46; Tambi&#233;n se observaron diferencias significativas relacionadas con el subtipo v&#237;rico &#40;en particular en los individuos infectados por AH1N1 &#40;86&#44;9 vs&#46; 65&#44;5&#37;&#44; p&#160;&#60;&#160;0&#44;001&#41;&#44; la necesidad de soporte de ventilaci&#243;n mec&#225;nica &#40;41&#44;8 vs&#46; 12&#44;8&#37;&#44; p&#160;&#60;&#160;0&#44;001&#41;&#44; ingreso en la UCI &#40;12&#44;1 vs&#46; 3&#44;0&#37;&#44; p&#160;<span class="elsevierStyleItalic">&#60;</span>&#160;0&#44;001&#41; y en la mayor&#237;a de las variables cl&#237;nicas y epidemiol&#243;gicas analizadas&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En el an&#225;lisis de regresi&#243;n m&#250;ltiple &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41; se asociaron dos factores modificables con una reducci&#243;n significativa del riesgo de muerte&#58; un antecedente de vacunaci&#243;n contra la gripe durante la misma estaci&#243;n de influenza &#40;RR&#160;&#61;&#160;0&#44;54&#59; IC&#160;95&#37;&#58; 0&#44;40-0&#44;75&#41; y el inicio del uso de f&#225;rmacos antivirales en las primeras 48 horas desde el inicio de la enfermedad aguda &#40;referencia&#58; cinco d&#237;as o m&#225;s&#59; RR&#160;&#61;&#160;0&#44;68&#59; IC&#160;95&#37;&#58; 0&#44;58-0&#44;81&#41;&#46; Como muestra la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#44; tras el ajuste de las m&#250;ltiples variables cl&#237;nicas y epidemiol&#243;gicas&#44; los pacientes con gripe asm&#225;ticos ten&#237;an una reducci&#243;n significativa en el riesgo de muerte a los 30 d&#237;as &#40;RR&#160;&#61;&#160;0&#44;66&#59; IC&#160;95&#37;&#58; 0&#44;47-0&#44;95&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Los factores asociados con un aumento de la letalidad hospitalaria a los 30 d&#237;as fueron&#58; sexo masculino &#40;RR&#160;&#61;&#160;1&#44;33&#59; IC&#160;95&#37;&#58; 1&#44;16-1&#44;52&#41;&#44; edad avanzada &#40;estrato de referencia&#44; 15-35 a&#241;os&#59; 36-55 a&#241;os&#44; RR&#160;&#61;&#160;2&#44;23&#44; IC&#160;95&#37;&#58; 1&#44;72-2&#44;90&#59; 56 a&#241;os o mayor&#44; RR&#160;&#61;&#160;3&#44;12&#44; IC&#160;95&#37;&#58; 2&#44;39-4&#44;06&#41; y el subtipo v&#237;rico &#40;referencia&#44; tipo B&#58; AH1N1&#44; RR&#160;&#61;&#160;1&#44;86&#44; IC&#160;95&#37;&#58; 1&#44;37-2&#44;53&#41;&#46; Otros factores de riesgo incluyeron la necesidad de soporte de ventilaci&#243;n mec&#225;nica durante la estancia hospitalaria &#40;RR&#160;&#61;&#160;3&#44;23&#59; IC&#160;95&#37;&#58; 2&#44;82-3&#44;72&#41; y un historial m&#233;dico de enfermedad renal cr&#243;nica &#40;RR&#160;&#61;&#160;1&#44;60&#59; IC&#160;95&#37;&#58; 1&#44;34-1&#44;92&#41; o de inmunosupresi&#243;n &#40;RR&#160;&#61;&#160;1&#44;21&#59; IC&#160;95&#37;&#58; 1&#44;01-1&#44;44&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall">Nuestros hallazgos sugieren que la mortalidad hospitalaria relacionada con el virus influenza en los subgrupos de individuos analizados fue alta&#46; Tambi&#233;n se muestra una reducci&#243;n significativa en el riesgo de muerte en individuos inmunizados contra la gripe y en aquellos que recibieron f&#225;rmacos antivirales poco despu&#233;s de la aparici&#243;n de la enfermedad aguda&#46; Dichos hallazgos refuerzan la importancia de la vacunaci&#243;n en la comunidad en los grupos de alto riego&#44; junto con la salvaguarda al acceso adecuado a los inhibidores de la neuraminidasa&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">En la mayor&#237;a de los pacientes adultos reclutados&#44; la muerte hospitalaria fue un acontecimiento temprano y m&#225;s de la mitad &#40;55&#44;7&#37;&#41; de los resultados fatales tuvieron lugar en los cinco primeros d&#237;as del ingreso hospitalario &#40;&#8804;&#160;1 d&#237;a&#44; 17&#44;4&#37;&#59; 2-3 d&#237;as&#44; 20&#44;2&#37;&#59; 4-5 d&#237;as&#44; 18&#44;1&#37;&#41;&#46; En los pacientes recuperados&#44; la estancia hospitalaria media fue menor que la de los pacientes fallecidos &#40;5&#44;8&#160;&#177;&#160;5&#44;1 vs&#46; 7&#44;7&#160;&#177;&#160;6&#44;6&#59; p&#160;&#60;&#160;0&#44;001&#41;&#44; pero el alta tuvo lugar despu&#233;s de ocho d&#237;as o m&#225;s en aproximadamente el 40&#37; &#40;39&#44;5&#37;&#41; de los pacientes&#46; Tambi&#233;n se document&#243; la mortalidad temprana de pacientes mexicanos con AH1N1 durante la pandemia del 2019<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Se han publicado tasas de mortalidad heterog&#233;neas en pacientes de gripe no ambulatorios&#46; Nuestra estimaci&#243;n &#40;18&#44;1&#37;&#41; fue mayor que la registrada para adultos en las poblaciones espa&#241;ola &#40;13&#44;0&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">16</span></a>&#44; canadiense &#40;9&#44;7&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">17</span></a> y brasile&#241;a &#40;13&#44;5&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">18</span></a>&#46; Se observ&#243; una mayor tasa de muerte &#40;41&#44;6&#37;&#41; en sujetos chinos con neumon&#237;a grave asociada a influenza A<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">19</span></a>&#46; La inclusi&#243;n de casos de mayor gravedad y con desenlace a largo plazo &#40;mortalidad de 60 d&#237;as&#41; podr&#237;a&#44; en parte&#44; condicionar dicho escenario&#46; Tambi&#233;n se registr&#243; un mayor riesgo de muerte &#40;29&#44;0&#37;&#41; en Eslovaquia<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">20</span></a>&#44; donde la media de edad de los casos graves fue sorprendentemente baja &#40;35 a&#241;os&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">La gripe es la principal causa de morbimortalidad en M&#233;xico y en otros pa&#237;ses latinoamericanos y caribe&#241;os&#44; principalmente en adultos mayores&#44; adolescentes y en pacientes con enfermedades respiratorias transmisibles<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">21</span></a>&#46; En el sistema de vigilancia utilizado &#40;SINOLAVE&#41;&#44; y como se muestra en la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#44; el 17&#44;5&#37; &#40;19&#46;614&#47;112&#46;295&#41; de los pacientes con gripe presentaron s&#237;ntomas graves y requirieron hospitalizaci&#243;n&#44; lo que aument&#243; el coste directo e indirecto de la enfermedad<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">22</span></a>&#46; Tambi&#233;n es alta la carga mundial de gripe&#44; particularmente en pa&#237;ses con ingresos bajos y medios<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">23</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">La vacunaci&#243;n frente a la gripe es una intervenci&#243;n de salud p&#250;blica de eficacia probada para reducir la carga asociada a la enfermedad<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">24</span></a>&#46; En un an&#225;lisis mexicano previo durante nueve a&#241;os &#40;2010-2018&#41;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">25</span></a>&#44; se describi&#243; una reducci&#243;n del riesgo de muerte en los pacientes vacunados frente a la gripe&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">De acuerdo con los datos de la Organizaci&#243;n Panamericana de la Salud&#44; la cobertura de la vacuna de la gripe&#44; en 2018&#44; fue del 94&#37; en adultos mexicanos de 65 a&#241;os o mayores<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">26</span></a> siendo una de las m&#225;s altas de la regi&#243;n&#46; En nuestro estudio&#44; el 12&#44;1&#37; &#40;83&#47;604&#41; de los individuos &#8805;&#160;65 a&#241;os se registraron como vacunados&#46; La prevalencia de la inmunizaci&#243;n en otros grupos de edad fue&#58; 15-29 a&#241;os del 15&#44;6&#37;&#59; 30-49 a&#241;os de 10&#44;7&#37;&#44; y 50-64 a&#241;os de 9&#44;2&#37; &#40;datos no presentados&#41;&#46; En otros grupos de alto riesgo &#40;por ejemplo&#44; pacientes inmunodeprimidos o aquellos con diabetes tipo 2&#41;&#44; la prevalencia de vacunaci&#243;n contra la gripe estacional tambi&#233;n fue baja&#44; oscilando entre 10-15&#37; &#40;datos no presentados&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">La vacuna trivalente contra la gripe se administra en la mayor&#237;a de los pa&#237;ses latinoamericanos&#46; El coste por dosis es bajo &#40;alrededor de &#36;2-4 USD&#41;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">27</span></a>&#44; lo que la hace muy rentable&#46; Entre 2014-2018&#44; el IMSS administr&#243;&#44; a nivel nacional&#44; una media de 11&#44;5 millones de dosis&#47;a&#241;o de vacunas contra la gripe estacional<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Son muchos los factores responsables de esta situaci&#243;n&#44; con variaciones individuales&#44; culturales y estructurales documentadas<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">29</span></a>&#46; Se han analizado las diferencias relacionadas con el sexo en cuanto a la aceptaci&#243;n de la vacunaci&#243;n&#44; pero los datos publicados son escasos y se ha observado una mayor cobertura de vacunaci&#243;n en los hombres<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">30-32</span></a>&#46; En nuestra muestra se observ&#243; un desplazamiento de los resultados y las mujeres eran m&#225;s propensas a vacunarse&#46; Son necesarios m&#225;s estudios para explicar estas diferencias&#46; Sin embargo&#44; planteamos la hip&#243;tesis de que la vacunaci&#243;n contra la gripe para mujeres embarazadas y un menor comportamiento preventivo de b&#250;squeda de atenci&#243;n m&#233;dica entre los hombres pueden estar determinando&#44; al menos parcialmente y en la poblaci&#243;n mexicana&#44; estos hallazgos<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">De acuerdo con el <span class="elsevierStyleItalic">International Study of Asthma and Allergies in Childhood &#40;ISAAC&#41;&#44;</span> en M&#233;xico la prevalencia de asma diagnosticada por un m&#233;dico &#40;diagnosticada en alg&#250;n momento&#41; ronda el 7&#37; y es una de las m&#225;s baja en Am&#233;rica Latina&#44; tras la frecuencia del 2&#44;6&#37; registrada en Guatemala<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">34</span></a>&#46; En un estudio poblacional en adultos mexicanos&#44; la prevalencia de asma diagnosticada por un m&#233;dico fue del 5&#37; &#40;hombres&#58; 3&#44;3&#37;&#59; mujeres&#58; 6&#44;2&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">35</span></a>&#46; En nuestro an&#225;lisis se observaron antecedentes de asma en el 5&#44;9&#37; de los sujetos &#40;hombres&#58; 3&#44;6&#37;&#59; mujeres&#58; 7&#44;8&#37;&#59; p&#160;&#60;&#160;0&#44;001&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Tanto los ni&#241;os como los adultos con antecedentes de asma son m&#225;s propensos a desarrollar enfermedades infecciosas respiratorias graves y a ser hospitalizados&#46; Durante la pandemia de gripe porcina del 2009&#44; se identific&#243; asma en el 10-20&#37; de los sujetos hospitalizados de todo el mundo<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">36</span></a>&#46; Numerosos factores determinan esta situaci&#243;n e incluyen aspectos de comportamiento en cuanto a la b&#250;squeda de atenci&#243;n m&#233;dica&#44; as&#237; como mayores precauciones m&#233;dicas<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">37</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Cuando se compara con los adultos asm&#225;ticos de nuestro an&#225;lisis&#44; y despu&#233;s de ajustar por otras exposiciones al riesgo&#44; los sujetos no asm&#225;ticos con infecci&#243;n por influenza grave tuvieron un aumento del 50&#37; en el riesgo de muerte &#40;RR&#160;&#61;&#160;1&#44;52&#44; IC&#160;95&#37;&#58; 1&#44;05-2&#44;13&#41;&#46; Ya se han publicado resultados similares en el Reino Unido en un an&#225;lisis nacional durante la pandemia 2009-2010 de AH1N1<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">38</span></a>&#46; El efecto relacionado con el asma sobre el riesgo de muerte por influenza es el resultado de mecanismos m&#250;ltiples y complejos y&#44; en general&#44; se cree que las respuestas inmunes alteradas que caracterizan a los pacientes asm&#225;ticos tambi&#233;n los protegen de las graves consecuencias asociadas a la gripe<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">36</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">La influenza AH1N1 fue el subtipo m&#225;s com&#250;n en los sujetos del presente estudio y se observ&#243; un mayor riesgo de desenlace fatal en sus portadores &#40;cuando se compara con la influenza B&#58; RR&#160;&#61;&#160;1&#44;86&#59; IC&#160;95&#37;&#58; 1&#44;37-2&#44;53&#41;&#46; Despu&#233;s de la pandemia del 2009&#44; el AH1N1 se ha documentado en la mayor&#237;a de los casos de gripe en M&#233;xico<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">39</span></a>&#46; Durante la &#250;ltima temporada de gripe &#40;2019-2020&#41; se ha repetido este hallazgo en la mayor&#237;a de los pa&#237;ses latinoamericanos<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">40</span></a>&#46; Este subtipo de alto riesgo se identific&#243; en el 71&#44;3 vs&#46; el 54&#44;2&#37; de los sujetos vacunados y no vacunados&#44; respectivamente&#44; recalcando&#44; una vez m&#225;s&#44; la importancia de fomentar la vacunaci&#243;n estacional frente a la gripe&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">El f&#225;rmaco antiviral contra la influenza&#44; oseltamivir&#44; est&#225; incluido en la lista de medicamentos indispensables que ofrece el IMSS a los asegurados<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">41</span></a>&#46; Todos los pacientes del estudio con enfermedad grave recibieron el tratamiento antiviral antes o durante la estancia hospitalaria&#46; Sin embargo&#44; uno de cada cuatro pacientes recibi&#243; el antiviral despu&#233;s de tres o m&#225;s d&#237;as de la aparici&#243;n de la enfermedad &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Los pacientes que recibieron la primera dosis de oseltamivir en los dos primeros d&#237;as de la enfermedad aguda mostraron una reducci&#243;n del riesgo de muerte del 32&#37; &#40;RR 0&#44;68&#59; IC&#160;95&#37;&#58; 0&#44;58-0&#44;81&#41; cuando se compara con aquellos pacientes que recibieron el antiviral en el d&#237;a cinco o posterior del inicio de la enfermedad &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">El n&#250;mero medio de d&#237;as desde la aparici&#243;n de los s&#237;ntomas hasta el ingreso hospitalario aument&#243; junto con la probabilidad de retraso en el inicio del tratamiento &#40;&#8804;&#160;2 d&#237;as&#44; 0&#44;9&#160;&#177;&#160;0&#44;8&#59; 3-4 d&#237;as&#44; 2&#44;3&#160;&#177;&#160;1&#44;3&#59; &#8805;&#160;5 d&#237;as&#44; 3&#44;8&#160;&#177;&#160;2&#44;3&#41;&#46; Las dificultades para buscar atenci&#243;n m&#233;dica son un determinante plausible que afecta al inicio adecuado del tratamiento antiviral y la consiguiente reducci&#243;n del riesgo de muerte&#46; Sin embargo&#44; estas posibles dificultades no se han evaluado porque no se hab&#237;an incluido entre los objetivos de nuestro estudio&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Los pacientes con gripe grave que necesitaron soporte respiratorio tuvieron un aumento de tres veces en el riesgo de morir &#40;RR&#160;&#61;&#160;3&#44;31&#59; IC&#160;95&#37;&#58; 2&#44;89-3&#44;79&#41;&#44; siendo la necesidad de respirador el factor de riesgo con mayor impacto sobre el riesgo de muerte&#46; Esta asociaci&#243;n podr&#237;a ser secundaria a la gravedad alta de la enfermedad en los pacientes en respiraci&#243;n asistida y&#47;o al desarrollo de complicaciones relacionadas con la influenza &#40;como la neumon&#237;a bacteriana secundaria o la miocarditis&#41;&#44; que son causas comunes del s&#237;ndrome de distr&#233;s respiratorio agudo &#40;SDRA&#41;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">42</span></a>&#46; Los pacientes con gripe y neumon&#237;a que necesitan soporte respiratorio tienen un mayor riesgo de SDRA<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">43</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">En el an&#225;lisis bivariado&#44; la mayor&#237;a de las enfermedades cr&#243;nicas no transmisibles medidas &#40;por ejemplo&#44; hipertensi&#243;n arterial&#44; diabetes tipo 2&#44; obesidad&#44; enfermedad pulmonar obstructiva cr&#243;nica y enfermedades cardiovasculares&#41; presentaron una asociaci&#243;n significativa con un aumento en el riesgo de muerte&#46; Sin embargo&#44; en el an&#225;lisis m&#250;ltiple &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#44; ninguna de esas exposiciones al riesgo &#40;excepto la insuficiencia renal cr&#243;nica &#91;IRC&#93; o la inmunosupresi&#243;n&#41;&#44; se asociaron significativamente con el riesgo de un desenlace mortal&#46; Fueron hallazgos interesantes&#44; ya que cuando se comparan con la media nacional&#44; los sujetos de la muestra presentan una mayor frecuencia de diabetes tipo 2 &#40;25&#44;9&#37; vs&#46; 10&#44;3&#37;&#41; y de hipertensi&#243;n arterial &#40;29&#44;6&#37; vs&#46; 18&#44;4&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">44</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">En el presente estudio solo se reclutaron los casos de influenza RT-qPCR positivos y el principal resultado desfavorable &#40;muerte&#41; se obtuvo a trav&#233;s de los respectivos certificados m&#233;dicos&#46; Los registros civiles de M&#233;xico son unos de los mejores del mundo<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">45</span></a>&#44; en especial para la poblaci&#243;n adulta<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">46</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Debemos mencionar las potenciales limitaciones de nuestro estudio&#46; Se defini&#243; un resultado general &#40;muerte hospitalaria en casos positivos por gripe&#41; y no discriminamos entre muertes por gripe o concomitantes con gripe&#46; De acuerdo con los est&#225;ndares normativos&#44; dicha distinci&#243;n depende de si se registra la gripe o no se registra como la causa subyacente de la muerte en el certificado de defunci&#243;n&#46; Estos datos se registran en un sistema de vigilancia &#40;Sistema Epidemiol&#243;gico y Estad&#237;stico de Muertes&#41; que no hemos utilizado&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusiones</span><p id="par0190" class="elsevierStylePara elsevierViewall">A pesar de los esfuerzos a largo plazo centrados en la prevenci&#243;n primaria de la gripe&#44; esta es una causa com&#250;n de muerte en los pacientes hospitalizados&#46; En nuestro estudio se identificaron varios factores de riesgo asociados con un aumento de la mortalidad en los pacientes positivos de gripe confirmados en laboratorio&#44; la mayor&#237;a de los cuales se relacionaron con enfermedades no transmisibles&#46; Adem&#225;s&#44; se document&#243; una disminuci&#243;n del riesgo de resultado de muerte tanto en individuos vacunados como en aquellos con acceso adecuado a f&#225;rmacos antivirales espec&#237;ficos para la gripe&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Las intervenciones de pol&#237;tica sanitaria dirigidas a la promoci&#243;n de estilos de vida saludables&#44; junto con la salvaguarda al acceso a las vacunas contra la gripe y la adecuada administraci&#243;n de los inhibidores de la neuraminidasa&#44; pueden ser &#250;tiles para reducir la mortalidad asociada a la gripe&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicto de intereses</span><p id="par0200" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Identificar los factores asociados a riesgo de muerte en pacientes adolescentes y adultos hospitalizados con gripe confirmada en laboratorio &#40;reacci&#243;n en cadena de la polimerasa con transcriptasa inversa&#41; en M&#233;xico durante temporadas consecutivas de gripe &#40;2018-2020&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Pacientes y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohorte retrospectivo en el que se utilizaron datos del sistema de vigilancia nacional con 3&#46;422 sujetos inscritos&#46; Se evalu&#243; la asociaci&#243;n entre el riesgo a la exposici&#243;n y el riesgo de letalidad hospitalaria durante 30 d&#237;as mediante el estudio de los riesgos relativos &#40;RR&#41; y los intervalos de confianza &#40;IC&#41; del 95&#37;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La tasa de letalidad fue del 18&#44;1&#37;&#46; Los antecedentes de vacunaci&#243;n frente a la gripe &#40;RR&#160;&#61;&#160;0&#44;56&#59; IC 95&#37;&#58; 0&#44;42-0&#44;78&#41;&#44; la administraci&#243;n de f&#225;rmacos antivirales &#40;&#8804;&#160;dos d&#237;as desde la aparici&#243;n de los s&#237;ntomas &#91;referencia&#58; &#8805;&#160;5 d&#237;as&#93;&#59; RR&#160;&#61;&#160;0&#44;68&#59; IC 95&#37;&#58; 0&#44;58-0&#44;81&#41; y el historial de asma &#40;RR&#160;&#61;&#160;0&#44;66&#59; IC 95&#37;&#58; 0&#44;47-0&#44;95&#41; mostraron efectos protectores frente a la muerte atribuible a la gripe&#46; La ventilaci&#243;n mec&#225;nica caus&#243; el mayor aumento del riesgo de muerte &#40;RR&#160;&#61;&#160;3&#44;31&#59; IC 95&#37;&#58; 2&#44;89-3&#44;79&#41;&#46; Tambi&#233;n se asoci&#243; a una mayor letalidad hospitalaria por gripe el hecho de ser hombre&#44; tener edad avanzada&#44; el subtipo AH1N1 y otras enfermedades cr&#243;nicas&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nuestros hallazgos recalcan la gran importancia de fomentar la inmunizaci&#243;n de individuos de alto riesgo&#44; a la vez que se asegura un tratamiento antiviral temprano y eficaz en los casos sospechosos de gripe&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To identify factors associated with the risk of death in adolescent and adult inpatients with laboratory-positive &#40;reverse-transcription polymerase chain reaction&#41; influenza in Mexico during consecutive influenza seasons &#40;2018-2020&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patients and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A retrospective cohort study used national surveillance system data&#44; enrolling 3422 individuals&#46; The association between various risk factors and 30-day in-hospital lethality were evaluated through risk ratios &#40;RR&#41; and 95&#37; confidence intervals &#40;CI&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The lethality rate was 18&#46;1&#37;&#46; Flu vaccination history &#40;RR&#160;&#61;&#160;0&#46;56&#44; 95&#37; CI 0&#46;42-0&#46;78&#41;&#44; early antiviral drug administration &#40;&#8804;&#160;two days from symptom onset &#91;reference &#8805;&#160;5 days&#93;&#44; RR&#160;&#61;&#160;0&#46;68&#44; 95&#37; CI 0&#46;58-0&#46;81&#41;&#44; and a history of asthma &#40;RR&#160;&#61;&#160;0&#46;66&#44; 95&#37; CI 0&#46;47-0&#46;95&#41; showed protective effects against influenza-attributable death&#46; Mechanical ventilator support produced the highest increase in death risk &#40;RR&#160;&#61;&#160;3&#46;31&#44; 95&#37; CI 2&#46;89-3&#46;79&#41;&#46; Male sex&#44; older age&#44; AH1N1 subtype&#44; and other chronic diseases were also associated with fatal in-hospital influenza-related outcomes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Our findings highlight the major relevance of promoting immunization in high-risk individuals&#44; together with ensuring early and effective antiviral management in suspected influenza cases&#46;</p></span>"
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                  \t\t\t\t">&#40;35&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vacunaci&#243;n contra la influenza</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vacunaci&#243;n contra el neumococo</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Estaci&#243;n en el inicio de la enfermedad aguda</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primavera&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">&#40;8&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Verano&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">277&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;8&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">236&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;6&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Oto&#241;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">488&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">411&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Duraci&#243;n de la estancia hospitalaria &#40;d&#237;as&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad &#40;IMC 30 o superior&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumo de tabaco &#40;siempre&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#44;23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Obesidad &#40;IMC &#8805;&#160;30&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;182&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vacunaci&#243;n contra la gripe</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;26-0&#44;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;40-0&#44;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Subtipo de influenza aislado</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">c</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;58-0&#44;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Soporte de respiraci&#243;n mec&#225;nica</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;4&#44;79-6&#44;06&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;2&#44;81-3&#44;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Ingreso en UCI</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;3&#44;27-6&#44;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;93-1&#44;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;198&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Antecedentes personales de Tabaquismo</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;05-1&#44;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;80-1&#44;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;650&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Enfermedad pulmonar obstructiva cr&#243;nica</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;22-1&#44;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;92-1&#44;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;249&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Asma</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;37-0&#44;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;47-0&#44;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hipertensi&#243;n arterial</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;40-1&#44;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;83-1&#44;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;629&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Enfermedad cardiovascular</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;25-2&#44;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;82-1&#44;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;808&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diabetes tipo 2</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;59-2&#44;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;92-1&#44;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;383&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Insuficiencia renal cr&#243;nica</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;88-2&#44;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;34-1&#44;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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ORIGINAL
Estudio de cohorte retrospectivo nacional para identificar los factores de riesgo de letalidad por hospitalización durante 30 días en casos de gripe confirmados por laboratorio
National retrospective cohort study to identify risk factors for in-hospital 30-day lethality in laboratory-confirmed cases of influenza
E. Murillo-Zamoraa, O. Mendoza-Canob, I. Delgado-Encisoc, J. Guzmán-Esquivelc,d,
Autor para correspondencia
pepeguzman_esquivel@outlook.com

Autor para correspondencia.
a Departamento de Epidemiología, Unidad de Medicina Familiar No. 19, Instituto Mexicano del Seguro Social, Colima, México
b Facultad de Ingeniería Civil, Universidad de Colima, Colima, México
c Facultad de Medicina, Universidad de Colima, Colima, México
d Unidad de Investigación en Epidemiología Clínica, Instituto Mexicano del Seguro Social, Colima, México
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y en 2006 empez&#243; a operar un sistema de vigilancia centinela de esta enfermedad<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a>&#46; Actualmente&#44; y conforme a los est&#225;ndares normativos&#44; la vacunaci&#243;n contra la gripe se ofrece de forma gratuita a adolescentes y adultos &#40;de 20 a 59 a&#241;os de edad&#41; con factores de riesgo conocidos &#40;por ejemplo&#44; asma no controlada&#44; paciente con VIH&#44; c&#225;ncer&#44; entre otros&#41;&#44; en todos los adultos de 60 a&#241;os o mayores&#44; mujeres embarazadas y sanitarios<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Durante el brote de 2009 de virus de influenza AH1N1 &#40;H1N1pdm09&#41;&#44; M&#233;xico experiment&#243; tres oleadas de gripe &#40;en primavera&#44; verano y oto&#241;o&#41; y una cuarta oleada que tuvo lugar en el invierno de 2011-2012<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">6-8</span></a>&#46; En comparaci&#243;n con otros pa&#237;ses&#44; el exceso de mortalidad observada en M&#233;xico debido al H1N1pdm09 parec&#237;a ser particularmente alta<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La evaluaci&#243;n de los factores de riesgo asociado con el riesgo de fallecer por este virus puede ser &#250;til a la hora de valorar la eficacia de los esfuerzos en pol&#237;ticas de salud p&#250;blica centrados en la reducci&#243;n de la carga de gripe&#44; particularmente cuando se analizan los factores prevenibles<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">10</span></a>&#46; El objetivo de este estudio fue identificar los factores asociados a riesgo de muerte en pacientes adolescentes y adultos hospitalizados con gripe confirmada mediante laboratorio en M&#233;xico durante dos temporadas consecutivas de 2018 a 2020&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0025" class="elsevierStylePara elsevierViewall">Llevamos a cabo un estudio retrospectivo de cohorte desde diciembre del 2019 a marzo del 2020&#46; Se identificaron sujetos potencialmente elegibles &#40;casos de infecci&#243;n por gripe no ambulatorios y confirmados por laboratorio mediante reacci&#243;n cuantitativa en cadena de la polimerasa de transcripci&#243;n inversa &#91;RT-qPCR&#93;&#41; a partir de los registros nominales de un sistema normativo nacional en l&#237;nea &#40;Sistema Online de Notificaci&#243;n para la Vigilancia Epidemiol&#243;gica de la Influenza&#59; acr&#243;nimo en espa&#241;ol SINOLAVE&#41;&#44; perteneciente al Instituto Mexicano del Seguro Social &#40;IMSS&#41;&#46; Seg&#250;n los est&#225;ndares internacionales&#44; los casos sospechosos de infecci&#243;n por gripe en M&#233;xico se registran primero como enfermedad similar a la influenza &#40;ILI&#41; o infecci&#243;n respiratoria aguda grave&#44; seg&#250;n corresponda<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">11&#44;12</span></a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Poblaci&#243;n de estudio</span><p id="par0030" class="elsevierStylePara elsevierViewall">Se seleccionaron individuos de 15 a&#241;os de edad o mayores&#44; 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inmunosupresi&#243;n&#44; enfermedad pulmonar obstructiva cr&#243;nica o enfermedad cardiovascular&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Tambi&#233;n se extrajeron de la base de datos utilizada otros datos cl&#237;nicos o epidemiol&#243;gicos&#58; vacunaci&#243;n frente a gripe en la misma estaci&#243;n del inicio de la enfermedad aguda &#40;s&#237;&#47;no&#41;&#44; subtipo de gripe identificado&#44; fechas &#40;inicio de la enfermedad&#44; ingreso y alta hospitalaria&#44; inicio del uso de medicamentos antivirales&#41; y empleo de soporte de ventilaci&#243;n mec&#225;nica durante la estancia hospitalaria o ingreso en la unidad de cuidados intensivos &#40;UCI&#41;&#46; La fuente principal de datos del sistema de vigilancia empleado fueron los registros m&#233;dicos y los certificados de defunci&#243;n&#44; cuando correspondieron&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultado</span><p id="par0045" class="elsevierStylePara elsevierViewall">La letalidad hospitalaria en los 30 primeros d&#237;as desde el ingreso por infecci&#243;n de gripe confirmada en el laboratorio fue el resultado principal en el resultado binario que inclu&#237;a la muerte por cualquier causa &#40;s&#237;&#47;no&#41;&#46; 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el nivel de significaci&#243;n en el 5&#37;&#46; Para valorar la asociaci&#243;n entre la exposici&#243;n al riesgo analizado y el riesgo de muerte en el hospital en los casos confirmados por el laboratorio se usaron los riesgos relativos &#40;RR&#41; y los intervalos de confianza &#40;IC&#41; del 95&#37;&#44; calculados mediante modelos de regresi&#243;n lineal generalizados&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Consideraciones &#233;ticas</span><p id="par0065" class="elsevierStylePara elsevierViewall">Este estudio fue aprobado por el Comit&#233; de &#201;tica e Investigaci&#243;n en Salud local &#40;601&#41; del IMSS&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Resultados</span><p id="par0070" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> se muestra el perfil del estudio y los datos de los 3&#46;422 individuos que se analizaron&#46; La letalidad hospitalaria total fue del 18&#44;1&#37; y fue m&#225;s elevada en pacientes de mayor edad &#40;15-35 a&#241;os&#44; 5&#44;7&#37;&#59; 36-55 a&#241;os&#44; 20&#37;&#44; 56 a&#241;os o mayores&#44; 52&#44;5&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> muestra las caracter&#237;sticas del estudio para las variables seleccionadas&#46; La mayor&#237;a de los participantes fueron mujeres &#40;56&#44;4&#37;&#41; y su media de edad &#40;&#177; la desviaci&#243;n est&#225;ndar&#41; fue de 48&#44;2&#160;&#177;&#160;18&#44;3 a&#241;os&#46; Casi dos tercios &#40;64&#44;7&#37;&#41; de los casos de gripe confirmados por laboratorio tuvieron lugar en invierno &#40;hemisferio Norte&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">La frecuencia de vacunaci&#243;n contra la gripe durante la misma temporada de influenza fue del 14&#44;1 y del 8&#44;3&#37;&#44; en mujeres y hombres&#44; respectivamente &#40;total&#44; 11&#44;5&#37;&#41;&#46; Tambi&#233;n fue baja la prevalencia de la inmunizaci&#243;n neumoc&#243;cica en los participantes mayores de 65 a&#241;os &#40;1&#44;5&#37;&#41; y no se observaron diferencias relacionadas con el sexo &#40;hombres&#44; 0&#44;5&#37;&#59; mujeres 2&#44;3&#37;&#59; p&#160;&#61;&#160;0&#44;124&#41;&#46; La estancia media hospitalaria fue de 7&#44;1&#160;&#177;&#160;8&#44;5 d&#237;as&#46; Las enfermedades cr&#243;nicas analizadas m&#225;s frecuentes fueron&#58; hipertensi&#243;n arterial&#44; diabetes tipo 2 y obesidad&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Al comparar los casos fatales y no fatales de influenza &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; los pacientes que principalmente no se recuperaron durante los 30 primeros d&#237;as tras el ingreso hospitalario fueron hombres &#40;58&#44;8 vs&#46; 40&#44;3&#37;&#44; p&#160;&#60;&#160;0&#44;001&#41;&#44; de 56 a&#241;os o mayores &#40;52&#44;5 vs&#46; 31&#44;6&#37;&#44; p&#160;&#60;&#160;0&#44;001&#41; y no vacunados contra la gripe &#40;95&#44;3&#37; vs&#46; 86&#44;9&#37;&#44; p&#160;&#60;&#160;0&#44;001&#41;&#46; Tambi&#233;n se observaron diferencias significativas relacionadas con el subtipo v&#237;rico &#40;en particular en los individuos infectados por AH1N1 &#40;86&#44;9 vs&#46; 65&#44;5&#37;&#44; p&#160;&#60;&#160;0&#44;001&#41;&#44; la necesidad de soporte de ventilaci&#243;n mec&#225;nica &#40;41&#44;8 vs&#46; 12&#44;8&#37;&#44; p&#160;&#60;&#160;0&#44;001&#41;&#44; ingreso en la UCI &#40;12&#44;1 vs&#46; 3&#44;0&#37;&#44; p&#160;<span class="elsevierStyleItalic">&#60;</span>&#160;0&#44;001&#41; y en la mayor&#237;a de las variables cl&#237;nicas y epidemiol&#243;gicas analizadas&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En el an&#225;lisis de regresi&#243;n m&#250;ltiple &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41; se asociaron dos factores modificables con una reducci&#243;n significativa del riesgo de muerte&#58; un antecedente de vacunaci&#243;n contra la gripe durante la misma estaci&#243;n de influenza &#40;RR&#160;&#61;&#160;0&#44;54&#59; IC&#160;95&#37;&#58; 0&#44;40-0&#44;75&#41; y el inicio del uso de f&#225;rmacos antivirales en las primeras 48 horas desde el inicio de la enfermedad aguda &#40;referencia&#58; cinco d&#237;as o m&#225;s&#59; RR&#160;&#61;&#160;0&#44;68&#59; IC&#160;95&#37;&#58; 0&#44;58-0&#44;81&#41;&#46; Como muestra la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#44; tras el ajuste de las m&#250;ltiples variables cl&#237;nicas y epidemiol&#243;gicas&#44; los pacientes con gripe asm&#225;ticos ten&#237;an una reducci&#243;n significativa en el riesgo de muerte a los 30 d&#237;as &#40;RR&#160;&#61;&#160;0&#44;66&#59; IC&#160;95&#37;&#58; 0&#44;47-0&#44;95&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Los factores asociados con un aumento de la letalidad hospitalaria a los 30 d&#237;as fueron&#58; sexo masculino &#40;RR&#160;&#61;&#160;1&#44;33&#59; IC&#160;95&#37;&#58; 1&#44;16-1&#44;52&#41;&#44; edad avanzada &#40;estrato de referencia&#44; 15-35 a&#241;os&#59; 36-55 a&#241;os&#44; RR&#160;&#61;&#160;2&#44;23&#44; IC&#160;95&#37;&#58; 1&#44;72-2&#44;90&#59; 56 a&#241;os o mayor&#44; RR&#160;&#61;&#160;3&#44;12&#44; IC&#160;95&#37;&#58; 2&#44;39-4&#44;06&#41; y el subtipo v&#237;rico &#40;referencia&#44; tipo B&#58; AH1N1&#44; RR&#160;&#61;&#160;1&#44;86&#44; IC&#160;95&#37;&#58; 1&#44;37-2&#44;53&#41;&#46; Otros factores de riesgo incluyeron la necesidad de soporte de ventilaci&#243;n mec&#225;nica durante la estancia hospitalaria &#40;RR&#160;&#61;&#160;3&#44;23&#59; IC&#160;95&#37;&#58; 2&#44;82-3&#44;72&#41; y un historial m&#233;dico de enfermedad renal cr&#243;nica &#40;RR&#160;&#61;&#160;1&#44;60&#59; IC&#160;95&#37;&#58; 1&#44;34-1&#44;92&#41; o de inmunosupresi&#243;n &#40;RR&#160;&#61;&#160;1&#44;21&#59; IC&#160;95&#37;&#58; 1&#44;01-1&#44;44&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall">Nuestros hallazgos sugieren que la mortalidad hospitalaria relacionada con el virus influenza en los subgrupos de individuos analizados fue alta&#46; Tambi&#233;n se muestra una reducci&#243;n significativa en el riesgo de muerte en individuos inmunizados contra la gripe y en aquellos que recibieron f&#225;rmacos antivirales poco despu&#233;s de la aparici&#243;n de la enfermedad aguda&#46; Dichos hallazgos refuerzan la importancia de la vacunaci&#243;n en la comunidad en los grupos de alto riego&#44; junto con la salvaguarda al acceso adecuado a los inhibidores de la neuraminidasa&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">En la mayor&#237;a de los pacientes adultos reclutados&#44; la muerte hospitalaria fue un acontecimiento temprano y m&#225;s de la mitad &#40;55&#44;7&#37;&#41; de los resultados fatales tuvieron lugar en los cinco primeros d&#237;as del ingreso hospitalario &#40;&#8804;&#160;1 d&#237;a&#44; 17&#44;4&#37;&#59; 2-3 d&#237;as&#44; 20&#44;2&#37;&#59; 4-5 d&#237;as&#44; 18&#44;1&#37;&#41;&#46; En los pacientes recuperados&#44; la estancia hospitalaria media fue menor que la de los pacientes fallecidos &#40;5&#44;8&#160;&#177;&#160;5&#44;1 vs&#46; 7&#44;7&#160;&#177;&#160;6&#44;6&#59; p&#160;&#60;&#160;0&#44;001&#41;&#44; pero el alta tuvo lugar despu&#233;s de ocho d&#237;as o m&#225;s en aproximadamente el 40&#37; &#40;39&#44;5&#37;&#41; de los pacientes&#46; Tambi&#233;n se document&#243; la mortalidad temprana de pacientes mexicanos con AH1N1 durante la pandemia del 2019<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Se han publicado tasas de mortalidad heterog&#233;neas en pacientes de gripe no ambulatorios&#46; Nuestra estimaci&#243;n &#40;18&#44;1&#37;&#41; fue mayor que la registrada para adultos en las poblaciones espa&#241;ola &#40;13&#44;0&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">16</span></a>&#44; canadiense &#40;9&#44;7&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">17</span></a> y brasile&#241;a &#40;13&#44;5&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">18</span></a>&#46; Se observ&#243; una mayor tasa de muerte &#40;41&#44;6&#37;&#41; en sujetos chinos con neumon&#237;a grave asociada a influenza A<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">19</span></a>&#46; La inclusi&#243;n de casos de mayor gravedad y con desenlace a largo plazo &#40;mortalidad de 60 d&#237;as&#41; podr&#237;a&#44; en parte&#44; condicionar dicho escenario&#46; Tambi&#233;n se registr&#243; un mayor riesgo de muerte &#40;29&#44;0&#37;&#41; en Eslovaquia<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">20</span></a>&#44; donde la media de edad de los casos graves fue sorprendentemente baja &#40;35 a&#241;os&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">La gripe es la principal causa de morbimortalidad en M&#233;xico y en otros pa&#237;ses latinoamericanos y caribe&#241;os&#44; principalmente en adultos mayores&#44; adolescentes y en pacientes con enfermedades respiratorias transmisibles<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">21</span></a>&#46; En el sistema de vigilancia utilizado &#40;SINOLAVE&#41;&#44; y como se muestra en la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#44; el 17&#44;5&#37; &#40;19&#46;614&#47;112&#46;295&#41; de los pacientes con gripe presentaron s&#237;ntomas graves y requirieron hospitalizaci&#243;n&#44; lo que aument&#243; el coste directo e indirecto de la enfermedad<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">22</span></a>&#46; Tambi&#233;n es alta la carga mundial de gripe&#44; particularmente en pa&#237;ses con ingresos bajos y medios<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">23</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">La vacunaci&#243;n frente a la gripe es una intervenci&#243;n de salud p&#250;blica de eficacia probada para reducir la carga asociada a la enfermedad<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">24</span></a>&#46; En un an&#225;lisis mexicano previo durante nueve a&#241;os &#40;2010-2018&#41;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">25</span></a>&#44; se describi&#243; una reducci&#243;n del riesgo de muerte en los pacientes vacunados frente a la gripe&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">De acuerdo con los datos de la Organizaci&#243;n Panamericana de la Salud&#44; la cobertura de la vacuna de la gripe&#44; en 2018&#44; fue del 94&#37; en adultos mexicanos de 65 a&#241;os o mayores<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">26</span></a> siendo una de las m&#225;s altas de la regi&#243;n&#46; En nuestro estudio&#44; el 12&#44;1&#37; &#40;83&#47;604&#41; de los individuos &#8805;&#160;65 a&#241;os se registraron como vacunados&#46; La prevalencia de la inmunizaci&#243;n en otros grupos de edad fue&#58; 15-29 a&#241;os del 15&#44;6&#37;&#59; 30-49 a&#241;os de 10&#44;7&#37;&#44; y 50-64 a&#241;os de 9&#44;2&#37; &#40;datos no presentados&#41;&#46; En otros grupos de alto riesgo &#40;por ejemplo&#44; pacientes inmunodeprimidos o aquellos con diabetes tipo 2&#41;&#44; la prevalencia de vacunaci&#243;n contra la gripe estacional tambi&#233;n fue baja&#44; oscilando entre 10-15&#37; &#40;datos no presentados&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">La vacuna trivalente contra la gripe se administra en la mayor&#237;a de los pa&#237;ses latinoamericanos&#46; El coste por dosis es bajo &#40;alrededor de &#36;2-4 USD&#41;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">27</span></a>&#44; lo que la hace muy rentable&#46; Entre 2014-2018&#44; el IMSS administr&#243;&#44; a nivel nacional&#44; una media de 11&#44;5 millones de dosis&#47;a&#241;o de vacunas contra la gripe estacional<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Son muchos los factores responsables de esta situaci&#243;n&#44; con variaciones individuales&#44; culturales y estructurales documentadas<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">29</span></a>&#46; Se han analizado las diferencias relacionadas con el sexo en cuanto a la aceptaci&#243;n de la vacunaci&#243;n&#44; pero los datos publicados son escasos y se ha observado una mayor cobertura de vacunaci&#243;n en los hombres<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">30-32</span></a>&#46; En nuestra muestra se observ&#243; un desplazamiento de los resultados y las mujeres eran m&#225;s propensas a vacunarse&#46; Son necesarios m&#225;s estudios para explicar estas diferencias&#46; Sin embargo&#44; planteamos la hip&#243;tesis de que la vacunaci&#243;n contra la gripe para mujeres embarazadas y un menor comportamiento preventivo de b&#250;squeda de atenci&#243;n m&#233;dica entre los hombres pueden estar determinando&#44; al menos parcialmente y en la poblaci&#243;n mexicana&#44; estos hallazgos<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">De acuerdo con el <span class="elsevierStyleItalic">International Study of Asthma and Allergies in Childhood &#40;ISAAC&#41;&#44;</span> en M&#233;xico la prevalencia de asma diagnosticada por un m&#233;dico &#40;diagnosticada en alg&#250;n momento&#41; ronda el 7&#37; y es una de las m&#225;s baja en Am&#233;rica Latina&#44; tras la frecuencia del 2&#44;6&#37; registrada en Guatemala<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">34</span></a>&#46; En un estudio poblacional en adultos mexicanos&#44; la prevalencia de asma diagnosticada por un m&#233;dico fue del 5&#37; &#40;hombres&#58; 3&#44;3&#37;&#59; mujeres&#58; 6&#44;2&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">35</span></a>&#46; En nuestro an&#225;lisis se observaron antecedentes de asma en el 5&#44;9&#37; de los sujetos &#40;hombres&#58; 3&#44;6&#37;&#59; mujeres&#58; 7&#44;8&#37;&#59; p&#160;&#60;&#160;0&#44;001&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Tanto los ni&#241;os como los adultos con antecedentes de asma son m&#225;s propensos a desarrollar enfermedades infecciosas respiratorias graves y a ser hospitalizados&#46; Durante la pandemia de gripe porcina del 2009&#44; se identific&#243; asma en el 10-20&#37; de los sujetos hospitalizados de todo el mundo<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">36</span></a>&#46; Numerosos factores determinan esta situaci&#243;n e incluyen aspectos de comportamiento en cuanto a la b&#250;squeda de atenci&#243;n m&#233;dica&#44; as&#237; como mayores precauciones m&#233;dicas<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">37</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Cuando se compara con los adultos asm&#225;ticos de nuestro an&#225;lisis&#44; y despu&#233;s de ajustar por otras exposiciones al riesgo&#44; los sujetos no asm&#225;ticos con infecci&#243;n por influenza grave tuvieron un aumento del 50&#37; en el riesgo de muerte &#40;RR&#160;&#61;&#160;1&#44;52&#44; IC&#160;95&#37;&#58; 1&#44;05-2&#44;13&#41;&#46; Ya se han publicado resultados similares en el Reino Unido en un an&#225;lisis nacional durante la pandemia 2009-2010 de AH1N1<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">38</span></a>&#46; El efecto relacionado con el asma sobre el riesgo de muerte por influenza es el resultado de mecanismos m&#250;ltiples y complejos y&#44; en general&#44; se cree que las respuestas inmunes alteradas que caracterizan a los pacientes asm&#225;ticos tambi&#233;n los protegen de las graves consecuencias asociadas a la gripe<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">36</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">La influenza AH1N1 fue el subtipo m&#225;s com&#250;n en los sujetos del presente estudio y se observ&#243; un mayor riesgo de desenlace fatal en sus portadores &#40;cuando se compara con la influenza B&#58; RR&#160;&#61;&#160;1&#44;86&#59; IC&#160;95&#37;&#58; 1&#44;37-2&#44;53&#41;&#46; Despu&#233;s de la pandemia del 2009&#44; el AH1N1 se ha documentado en la mayor&#237;a de los casos de gripe en M&#233;xico<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">39</span></a>&#46; Durante la &#250;ltima temporada de gripe &#40;2019-2020&#41; se ha repetido este hallazgo en la mayor&#237;a de los pa&#237;ses latinoamericanos<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">40</span></a>&#46; Este subtipo de alto riesgo se identific&#243; en el 71&#44;3 vs&#46; el 54&#44;2&#37; de los sujetos vacunados y no vacunados&#44; respectivamente&#44; recalcando&#44; una vez m&#225;s&#44; la importancia de fomentar la vacunaci&#243;n estacional frente a la gripe&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">El f&#225;rmaco antiviral contra la influenza&#44; oseltamivir&#44; est&#225; incluido en la lista de medicamentos indispensables que ofrece el IMSS a los asegurados<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">41</span></a>&#46; Todos los pacientes del estudio con enfermedad grave recibieron el tratamiento antiviral antes o durante la estancia hospitalaria&#46; Sin embargo&#44; uno de cada cuatro pacientes recibi&#243; el antiviral despu&#233;s de tres o m&#225;s d&#237;as de la aparici&#243;n de la enfermedad &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Los pacientes que recibieron la primera dosis de oseltamivir en los dos primeros d&#237;as de la enfermedad aguda mostraron una reducci&#243;n del riesgo de muerte del 32&#37; &#40;RR 0&#44;68&#59; IC&#160;95&#37;&#58; 0&#44;58-0&#44;81&#41; cuando se compara con aquellos pacientes que recibieron el antiviral en el d&#237;a cinco o posterior del inicio de la enfermedad &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">El n&#250;mero medio de d&#237;as desde la aparici&#243;n de los s&#237;ntomas hasta el ingreso hospitalario aument&#243; junto con la probabilidad de retraso en el inicio del tratamiento &#40;&#8804;&#160;2 d&#237;as&#44; 0&#44;9&#160;&#177;&#160;0&#44;8&#59; 3-4 d&#237;as&#44; 2&#44;3&#160;&#177;&#160;1&#44;3&#59; &#8805;&#160;5 d&#237;as&#44; 3&#44;8&#160;&#177;&#160;2&#44;3&#41;&#46; Las dificultades para buscar atenci&#243;n m&#233;dica son un determinante plausible que afecta al inicio adecuado del tratamiento antiviral y la consiguiente reducci&#243;n del riesgo de muerte&#46; Sin embargo&#44; estas posibles dificultades no se han evaluado porque no se hab&#237;an incluido entre los objetivos de nuestro estudio&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Los pacientes con gripe grave que necesitaron soporte respiratorio tuvieron un aumento de tres veces en el riesgo de morir &#40;RR&#160;&#61;&#160;3&#44;31&#59; IC&#160;95&#37;&#58; 2&#44;89-3&#44;79&#41;&#44; siendo la necesidad de respirador el factor de riesgo con mayor impacto sobre el riesgo de muerte&#46; Esta asociaci&#243;n podr&#237;a ser secundaria a la gravedad alta de la enfermedad en los pacientes en respiraci&#243;n asistida y&#47;o al desarrollo de complicaciones relacionadas con la influenza &#40;como la neumon&#237;a bacteriana secundaria o la miocarditis&#41;&#44; que son causas comunes del s&#237;ndrome de distr&#233;s respiratorio agudo &#40;SDRA&#41;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">42</span></a>&#46; Los pacientes con gripe y neumon&#237;a que necesitan soporte respiratorio tienen un mayor riesgo de SDRA<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">43</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">En el an&#225;lisis bivariado&#44; la mayor&#237;a de las enfermedades cr&#243;nicas no transmisibles medidas &#40;por ejemplo&#44; hipertensi&#243;n arterial&#44; diabetes tipo 2&#44; obesidad&#44; enfermedad pulmonar obstructiva cr&#243;nica y enfermedades cardiovasculares&#41; presentaron una asociaci&#243;n significativa con un aumento en el riesgo de muerte&#46; Sin embargo&#44; en el an&#225;lisis m&#250;ltiple &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#44; ninguna de esas exposiciones al riesgo &#40;excepto la insuficiencia renal cr&#243;nica &#91;IRC&#93; o la inmunosupresi&#243;n&#41;&#44; se asociaron significativamente con el riesgo de un desenlace mortal&#46; Fueron hallazgos interesantes&#44; ya que cuando se comparan con la media nacional&#44; los sujetos de la muestra presentan una mayor frecuencia de diabetes tipo 2 &#40;25&#44;9&#37; vs&#46; 10&#44;3&#37;&#41; y de hipertensi&#243;n arterial &#40;29&#44;6&#37; vs&#46; 18&#44;4&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">44</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">En el presente estudio solo se reclutaron los casos de influenza RT-qPCR positivos y el principal resultado desfavorable &#40;muerte&#41; se obtuvo a trav&#233;s de los respectivos certificados m&#233;dicos&#46; Los registros civiles de M&#233;xico son unos de los mejores del mundo<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">45</span></a>&#44; en especial para la poblaci&#243;n adulta<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">46</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Debemos mencionar las potenciales limitaciones de nuestro estudio&#46; Se defini&#243; un resultado general &#40;muerte hospitalaria en casos positivos por gripe&#41; y no discriminamos entre muertes por gripe o concomitantes con gripe&#46; De acuerdo con los est&#225;ndares normativos&#44; dicha distinci&#243;n depende de si se registra la gripe o no se registra como la causa subyacente de la muerte en el certificado de defunci&#243;n&#46; Estos datos se registran en un sistema de vigilancia &#40;Sistema Epidemiol&#243;gico y Estad&#237;stico de Muertes&#41; que no hemos utilizado&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusiones</span><p id="par0190" class="elsevierStylePara elsevierViewall">A pesar de los esfuerzos a largo plazo centrados en la prevenci&#243;n primaria de la gripe&#44; esta es una causa com&#250;n de muerte en los pacientes hospitalizados&#46; En nuestro estudio se identificaron varios factores de riesgo asociados con un aumento de la mortalidad en los pacientes positivos de gripe confirmados en laboratorio&#44; la mayor&#237;a de los cuales se relacionaron con enfermedades no transmisibles&#46; Adem&#225;s&#44; se document&#243; una disminuci&#243;n del riesgo de resultado de muerte tanto en individuos vacunados como en aquellos con acceso adecuado a f&#225;rmacos antivirales espec&#237;ficos para la gripe&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Las intervenciones de pol&#237;tica sanitaria dirigidas a la promoci&#243;n de estilos de vida saludables&#44; junto con la salvaguarda al acceso a las vacunas contra la gripe y la adecuada administraci&#243;n de los inhibidores de la neuraminidasa&#44; pueden ser &#250;tiles para reducir la mortalidad asociada a la gripe&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicto de intereses</span><p id="par0200" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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    "fechaRecibido" => "2020-04-15"
    "fechaAceptado" => "2020-05-15"
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    "resumen" => array:2 [
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Identificar los factores asociados a riesgo de muerte en pacientes adolescentes y adultos hospitalizados con gripe confirmada en laboratorio &#40;reacci&#243;n en cadena de la polimerasa con transcriptasa inversa&#41; en M&#233;xico durante temporadas consecutivas de gripe &#40;2018-2020&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Pacientes y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohorte retrospectivo en el que se utilizaron datos del sistema de vigilancia nacional con 3&#46;422 sujetos inscritos&#46; Se evalu&#243; la asociaci&#243;n entre el riesgo a la exposici&#243;n y el riesgo de letalidad hospitalaria durante 30 d&#237;as mediante el estudio de los riesgos relativos &#40;RR&#41; y los intervalos de confianza &#40;IC&#41; del 95&#37;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La tasa de letalidad fue del 18&#44;1&#37;&#46; Los antecedentes de vacunaci&#243;n frente a la gripe &#40;RR&#160;&#61;&#160;0&#44;56&#59; IC 95&#37;&#58; 0&#44;42-0&#44;78&#41;&#44; la administraci&#243;n de f&#225;rmacos antivirales &#40;&#8804;&#160;dos d&#237;as desde la aparici&#243;n de los s&#237;ntomas &#91;referencia&#58; &#8805;&#160;5 d&#237;as&#93;&#59; RR&#160;&#61;&#160;0&#44;68&#59; IC 95&#37;&#58; 0&#44;58-0&#44;81&#41; y el historial de asma &#40;RR&#160;&#61;&#160;0&#44;66&#59; IC 95&#37;&#58; 0&#44;47-0&#44;95&#41; mostraron efectos protectores frente a la muerte atribuible a la gripe&#46; La ventilaci&#243;n mec&#225;nica caus&#243; el mayor aumento del riesgo de muerte &#40;RR&#160;&#61;&#160;3&#44;31&#59; IC 95&#37;&#58; 2&#44;89-3&#44;79&#41;&#46; Tambi&#233;n se asoci&#243; a una mayor letalidad hospitalaria por gripe el hecho de ser hombre&#44; tener edad avanzada&#44; el subtipo AH1N1 y otras enfermedades cr&#243;nicas&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nuestros hallazgos recalcan la gran importancia de fomentar la inmunizaci&#243;n de individuos de alto riesgo&#44; a la vez que se asegura un tratamiento antiviral temprano y eficaz en los casos sospechosos de gripe&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To identify factors associated with the risk of death in adolescent and adult inpatients with laboratory-positive &#40;reverse-transcription polymerase chain reaction&#41; influenza in Mexico during consecutive influenza seasons &#40;2018-2020&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patients and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A retrospective cohort study used national surveillance system data&#44; enrolling 3422 individuals&#46; The association between various risk factors and 30-day in-hospital lethality were evaluated through risk ratios &#40;RR&#41; and 95&#37; confidence intervals &#40;CI&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The lethality rate was 18&#46;1&#37;&#46; Flu vaccination history &#40;RR&#160;&#61;&#160;0&#46;56&#44; 95&#37; CI 0&#46;42-0&#46;78&#41;&#44; early antiviral drug administration &#40;&#8804;&#160;two days from symptom onset &#91;reference &#8805;&#160;5 days&#93;&#44; RR&#160;&#61;&#160;0&#46;68&#44; 95&#37; CI 0&#46;58-0&#46;81&#41;&#44; and a history of asthma &#40;RR&#160;&#61;&#160;0&#46;66&#44; 95&#37; CI 0&#46;47-0&#46;95&#41; showed protective effects against influenza-attributable death&#46; Mechanical ventilator support produced the highest increase in death risk &#40;RR&#160;&#61;&#160;3&#46;31&#44; 95&#37; CI 2&#46;89-3&#46;79&#41;&#46; Male sex&#44; older age&#44; AH1N1 subtype&#44; and other chronic diseases were also associated with fatal in-hospital influenza-related outcomes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Our findings highlight the major relevance of promoting immunization in high-risk individuals&#44; together with ensuring early and effective antiviral management in suspected influenza cases&#46;</p></span>"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Perfil del estudio&#44; M&#233;xico 2018-2020&#46; SINOLAVE&#58; acr&#243;nimo espa&#241;ol para Sistema de Notificaci&#243;n Online de Vigilancia Epidemiol&#243;gica de la Influenza&#44; un sistema online perteneciente al Instituto Mexicano del Seguro Social&#59; RT-qPCR&#58; reacci&#243;n cuantitativa en cadena de la polimerasa de transcripci&#243;n inversa&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Vacunaci&#243;n contra el neumococo</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " colspan="8" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estaci&#243;n en el inicio de la enfermedad aguda</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primavera&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Invierno&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Subtipo de influenza aislado</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Recibi&#243; ventilaci&#243;n mec&#225;nica en el hospital</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inicio de los f&#225;rmacos antivirales<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">774&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Con antecedentes personales de&#8230;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hipertensi&#243;n arterial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes tipo 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Asma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad &#40;IMC 30 o superior&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enfermedad renal cr&#243;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumo de tabaco &#40;siempre&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inmunosupresi&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>EPOC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>56-98&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;3&#44;62-6&#44;14&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;2&#44;39-4&#44;06&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Obesidad &#40;IMC &#8805;&#160;30&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;31-1&#44;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;96-1&#44;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;182&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vacunaci&#243;n contra la gripe</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;26-0&#44;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;40-0&#44;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Subtipo de influenza aislado</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">c</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AH1N1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;2&#44;34-4&#44;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;37-2&#44;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AH3N2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;81-1&#44;86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;342&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;61-1&#44;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;648&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Estaci&#243;n de aparici&#243;n de s&#237;ntomas</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">d</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primavera&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;3&#44;27-6&#44;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;93-1&#44;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;198&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Antecedentes personales de Tabaquismo</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;05-1&#44;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;80-1&#44;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;650&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Enfermedad pulmonar obstructiva cr&#243;nica</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;22-1&#44;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;92-1&#44;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;249&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Asma</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;37-0&#44;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;47-0&#44;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hipertensi&#243;n arterial</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;40-1&#44;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;83-1&#44;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;629&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Enfermedad cardiovascular</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Virus de influenza B fue aislado en 538 pacientes&#58; L&#237;nea-Victoria&#44; 48&#37;&#59; L&#237;nea B-Yamagata&#44; 44&#37;&#59; No-subtipo&#44; 8&#37;&#46;</p>"
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                    0 => array:2 [
                      "titulo" => "A systematic review and meta-analysis of the direct epidemiological and economic effects of seasonal influenza vaccination on healthcare workers"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46; Imai"
                            1 => "M&#46; Toizumi"
                            2 => "L&#46; Hall"
                            3 => "S&#46; Lambert"
                            4 => "K&#46; Halton"
                            5 => "K&#46; Merollini"
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                        "fecha" => "2018"
                        "volumen" => "13"
                        "paginaInicial" => "e0198685"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29879206"
                            "web" => "Medline"
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              "etiqueta" => "2"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "The Burden of Influenza&#58; a Complex Problem"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Gordon"
                            1 => "A&#46; Reingold"
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Información del artículo
ISSN: 00142565
Idioma original: Español
DOI:10.1016/j.rce.2020.05.016
Datos actualizados diariamente
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2020 Diciembre 2 2 4
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