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Small trials have suggested that heterologous vaccination with first-dose ChAdOx1 and second-dose BNT162b2 may generate a better immune response than homologous vaccination with two doses of ChAdOx1. In this cohort analysis, we use linked data from Catalonia (Spain), where those aged <60 who received a first dose of ChAdOx1 could choose between ChAdOx1 and BNT162b2 for their second dose. Comparable cohorts were obtained after exact-matching 14,325/17,849 (80.3%) people receiving heterologous vaccination to 14,325/149,386 (9.6%) receiving homologous vaccination by age, sex, region, and date of second dose. Of these, 464 (3.2%) in the heterologous and 694 (4.8%) in the homologous groups developed COVID-19 between 1st June 2021 and 5th December 2021. The resulting hazard ratio (95% confidence interval) is 0.66 [0.59–0.74], favouring heterologous vaccination. The two groups had similar testing rates and safety outcomes. Sensitivity and negative control outcome analyses confirm these findings. In conclusion, we demonstrate that a heterologous vaccination schedule with ChAdOx1 followed by BNT162b2 was more efficacious than and similarly safe to homologous vaccination with two doses of ChAdOx1. Most of the infections in our study occurred when Delta was the predominant SARS-CoV-2 variant in Spain. These data agree with previous phase 2 randomised trials. Different homologous and heterologous vaccination regimens have been used for COVID-19. Here the authors show in a cohort analysis from Catalonia that heterologous vaccination with ChAdOx1 followed by BNT162b2 has better vaccine effectiveness than two doses of ChAdOx1.

ObjectiveCancer care has been disrupted by the response of health systems to the COVID-19 pandemic, especially during lockdowns. The objective of our study is to evaluate the impact of the pandemic on the incidence of cancer diagnoses in primary care.DesignTime-series study of malignant neoplasms and diagnostic procedures, using data from the primary care electronic health records from January 2014 to September 2020.SettingPrimary care, Catalonia, Spain.ParticipantsPeople older than 14 years and assigned in one of the primary care practices of the Catalan Institute of Health with a new diagnosis of malignant neoplasm.Main outcome measuresWe obtained the monthly expected incidence of malignant neoplasms using a temporary regression, where the response variable was the incidence of cancer from 2014 to 2018 and the adjustment variables were the trend and seasonality of the time series. Excess or lack of malignant neoplasms was defined as the number of observed minus expected cases, globally and stratified by sex, age, type of cancer and socioeconomic status.ResultsBetween March and September 2020 we observed 8766 (95% CI 4135 to 13 397) fewer malignant neoplasm diagnoses, representing a reduction of 34% (95% CI 19.5% to 44.1%) compared with the expected. This underdiagnosis was greater in individuals aged older than 64 years, men and in some types of cancers (skin, colorectal, prostate). Although the reduction was predominantly focused during the lockdown, expected figures have not yet been reached (40.5% reduction during the lockdown and 24.3% reduction after that).ConclusionsReduction in cancer incidence has been observed during and after the lockdown. Urgent policy interventions are necessary to mitigate the indirect effects of the COVID-19 pandemic and related control measures on other diseases and some strategies must be designed in order to reduce the underdiagnosis of cancer.

Area-based measures of economic deprivation are seldom applied to large medical records databases to establish population-scale associations between deprivation and disease. To study the association between deprivation and incidence of common cancer types in a Southern European region. Retrospective ecological study using the SIDIAP (Information System for the Development of Research in Primary Care) database of longitudinal electronic medical records for a representative population of Catalonia (Spain) and the MEDEA index based on urban socioeconomic indicators in the Spanish census. Study outcomes were incident cervical, breast, colorectal, prostate, and lung cancer in 2009-2012. The completeness of SIDIAP cancer recording was evaluated through linkage of a geographic data subset to a hospital cancer registry. Associations between MEDEA quintiles and cancer incidence was evaluated using zero-inflated Poisson regression adjusted for sex, age, smoking, alcoholism, obesity, hypertension, and diabetes. SIDIAP sensitivity was 63% to 92% for the five cancers studied. There was direct association between deprivation and lung, colorectal, and cervical cancer: incidence rate ratios (IRR) 1.82 [1.64-2.01], IRR 1.60 [1.34-1.90], IRR 1.22 [1.07-1.38], respectively, comparing the most deprived to most affluent areas. In wealthy areas, prostate and breast cancers were more common: IRR 0.92 [0.80-1.00], IRR 0.91 [0.78-1.06]. Adjustment for confounders attenuated the association with lung cancer risk (fully adjusted IRR 1.16 [1.08-1.25]), reversed the direction of the association with colorectal cancer (IRR 0.90 [0.84-0.95]), and did not modify the associations with cervical (IRR 1.27 [1.11-1.45]), prostate (0.74 [0.69-0.80]), and breast (0.76 [0.71-0.81]) cancer. Deprivation is associated differently with the occurrence of various cancer types. These results provide evidence that MEDEA is a useful, area-based deprivation index for analyses of the SIDIAP database. This information will be useful to improve screening programs, cancer prevention and management strategies, to reach patients more effectively, particularly in deprived urban areas.

Background Pneumonia is one of the complications of COVID-19. Primary care electronic health records (EHR) have shown the utility as a surveillance system. We therefore analyse the trends of pneumonia during two waves of COVID-19 pandemic in order to use it as a clinical surveillance system and an early indicator of severity. Methods Time series analysis of pneumonia cases, from January 2014 to December 2020. We collected pneumonia diagnoses from primary care EHR, a software system covering > 6 million people in Catalonia (Spain). We compared the trend of pneumonia in the season 2019–2020 with that in the previous years. We estimated the expected pneumonia cases with data from 2014 to 2018 using a time series regression adjusted by seasonality and influenza epidemics. Results Between 4 March and 5 May 2020, 11,704 excess pneumonia cases (95% CI: 9909 to 13,498) were identified. Previously, we identified an excess from January to March 2020 in the population older than 15 years of 20%. We observed another excess pneumonia period from 22 october to 15 november of 1377 excess cases (95% CI: 665 to 2089). In contrast, we observed two great periods with reductions of pneumonia cases in children, accounting for 131 days and 3534 less pneumonia cases (95% CI, 1005 to 6064) from March to July; and 54 days and 1960 less pneumonia cases (95% CI 917 to 3002) from October to December. Conclusions Diagnoses of pneumonia from the EHR could be used as an early and low cost surveillance system to monitor the spread of COVID-19.

Background: The MVA-BN vaccine is considered effective for preventing mpox in key populations, based on observational studies, though no randomized trials have yet confirmed its effectiveness. Observational studies published to date rely on retrospective analyses of routine data, often missing information on relevant risk factors for mpox. Methods: Multi-country target trial emulation study with prospective data collection. Between 1 September 2022 and 15 June 2023, we recruited individuals eligible for mpox vaccination based on clinical history and exposure behaviors via healthcare centers and social venues in Spain, Peru, Panama, and Chile. Vaccinated individuals were paired with unvaccinated counterparts matched by mpox risk factors, country, recruitment date, and age. Follow-up continued via periodic surveys until 31 March 2024. The primary endpoint was symptomatic mpox occurrence ≥14 days post-vaccination. Results: The primary analysis included 1028 individuals (514 vaccinated, 514 unvaccinated) with a median follow-up time of 9.3 months (IQR 4.7–13.7). Mpox occurred in eight participants (0.8%): three vaccinated and five unvaccinated (HR 0.6; 95% CI 0.21–1.70). Adverse reactions were reported by 731 (49.6%) participants, predominantly skin reactions (703/1475; 47.7%), while systemic reactions occurred in 107 (7.3%). Long-lasting erythema at the injection site was reported in 450/1058 (42.5%) participants, persisting >6 months in 107 of them (23.8%). Conclusions: The low incidence of mpox during the study period resulted in a limited number of endpoint events, precluding robust conclusions on the efficacy of the MVA-BN vaccine as pre-exposure prevention for mpox. However, our analysis, which accounted for key confounders such as exposure behaviors, yielded results consistent with previous studies suggesting the effectiveness of the vaccine in the mpox setting.

Background The incidence of chronic diseases during the COVID-19 pandemic has drastically been reduced worldwide due to disruptions in healthcare systems. The aim of our study is to analyse the trends in the incidence of 7 commonly managed primary care chronic diseases during the last 2 years of the COVID-19 pandemic in Catalonia. Methods We performed an observational retrospective population-based study using data from primary care electronic health records from January 2018 to August 2022 (5.1 million people older than 14 years). We divided the study period into two: a pre-pandemic period (before 14 March 2020) and a pandemic period. We performed a segmented regression analysis of daily incidence rates per 100,000 inhabitants of 7 chronic diseases: type 2 diabetes mellitus (T2DM), asthma, chronic obstructive pulmonary disease (COPD), ischemic heart disease (IHD), heart failure (HF), hypertension and hypercholesterolemia. In addition, we compared annual incidence between pandemic years (2020, 2021 and 2022) and 2019. Associated incidence rate ratios (IRR) were also calculated. Finally, we estimated the number of expected diagnoses during the pandemic period using data from 2019 and we compared it with the observed data. Results We analysed 740,820 new chronic diseases’ diagnoses. Daily incidence rates of all 7 chronic diseases were drastically interrupted on 14 March 2020, and a general upward trend was observed during the following months. Reductions in 2020 were around 30% for all conditions except COPD which had greater reductions (IRR: 0.58 [95% CI: 0.57 to 0.6]) and HF with lesser drops (IRR: 0.86 [95% CI: 0.84 to 0.88]). Some of the chronic conditions have returned to pre-pandemic diagnosis levels, except asthma, COPD and IHD. The return to pre-pandemic diagnosis levels compensated for the drops in 2020 for T2DM and HF, but not for hypertension which presented an incomplete recovery. We also observed an excess of hypercholesterolemia diagnoses of 8.5% (95%CI: 1.81% to 16.15%). Conclusions Although primary care has recovered the pre-pandemic diagnosis levels for some chronic diseases, there are still missing diagnoses of asthma, COPD and IHD that should be addressed.

Background To determine the effectiveness of reminders compared to no reminders in improving adherence to multiple clinical recommendations measured as the resolution of the clinical condition that motivated the reminder, in a primary care setting with a well-established feedback system. Methods/design A 12-month, cluster-randomized, controlled clinical trial was designed (randomized by primary care team) to evaluate the impact of computerized reminders. All study participants will continue to receive the usual feedback from the electronic health records system. The control group (well-established feedback) will be compared with reminders and a well-established feedback system. The study will include all general practitioners (3425) and nurses (3262) providing primary care for a population aged 14 years or older in the 282 primary care teams reporting to the Catalan Institute of Health. Up to 10 clinical reminders are offered for each patient, recommending action related to at least one of nine clinical conditions: arterial hypertension, elevated cardiovascular risk, type 2 diabetes mellitus, cerebrovascular accident, ischemic heart disease, heart failure, atrial fibrillation, smoking habit, and hepatitis C. The outcomes are the resolution of the clinical condition that motivated the reminder and the time elapsed between the first reminder message and implementation of the recommended action (months). Due to the obvious correlation between reminders about the same patient, the profile of patients assigned to a particular professional, and the professionals assigned to a particular centre, hierarchical modelling will be used to simultaneously estimate the effect of the study variables at these different levels of analysis. To estimate the impact of the intervention arm, an analysis of adherence to each type of reminder will be carried out, using multi-level logistical regression models at level of the primary care centre. Time to adherence will be estimated by the Kaplan–Meier method and comparisons will be done using the log-rank test. Discussion The results of this study could provide new evidence on the impact of computerized reminders at the point of care on adherence to clinical guidelines in primary care with an established feedback system. Trial registration ISRCTN42391639. October 8, 2012

ObjectiveTo assess the effectiveness of mandatory use of face covering masks (FCMs) in schools during the first term of the 2021–2022 academic year.DesignA retrospective population-based study.SettingSchools in Catalonia (Spain).Population599 314 children aged 3–11 years attending preschool (3–5 years, without FCM mandate) and primary education (6–11 years, with FCM mandate).Study periodFrom 13 September to 22 December 2021 (before Omicron variant).InterventionsA quasi-experimental comparison between children in the last grade of preschool (5 years old), as a control group, and children in year 1 of primary education (6 years old), as an interventional group.Main outcome measuresIncidence of SARS-CoV-2, secondary attack rates (SARs) and effective reproductive number (R*).ResultsSARS-CoV-2 incidence was significantly lower in preschool than in primary education, and an increasing trend with age was observed. Six-year-old children showed higher incidence than 5 year olds (3.54% vs 3.1%; OR 1.15 (95% CI 1.08 to 1.22)) and slightly lower but not statistically significant SAR (4.36% vs 4.59%; incidence risk ratio 0.96 (95% CI 0.82 to 1.11)) and R* (0.9 vs 0.93; OR 0.96 (95% CI 0.87 to 1.09)). Results remained consistent using a regression discontinuity design and linear regression extrapolation approaches.ConclusionsWe found no significant differences in SARS-CoV-2 transmission due to FCM mandates in Catalonian schools. Instead, age was the most important factor in explaining the transmission risk for children attending school.

Nursing homes have accounted for a significant part of SARS-CoV-2 mortality, causing great social alarm. Using data collected from electronic medical records of 1,319,839 institutionalised and non-institutionalised persons ≥ 65 years, the present study investigated the epidemiology and differential characteristics between these two population groups. Our results showed that the form of presentation of the epidemic outbreak, as well as some risk factors, are different among the elderly institutionalised population with respect to those who are not. In addition to a twenty-fold increase in the rate of adjusted mortality among institutionalised individuals, the peak incidence was delayed by approximately three weeks. Having dementia was shown to be a risk factor for death, and, unlike the non-institutionalised group, neither obesity nor age were shown to be significantly associated with the risk of death among the institutionalised. These differential characteristics should be able to guide the actions to be taken by the health administration in the event of a similar infectious situation among institutionalised elderly people.

Purpose: The primary aim of this work was to convert the Information System for Research in Primary Care (SIDIAP) from Catalonia, Spain, to the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). Our second aim was to provide a descriptive analysis of COVID-19-related outcomes among the general population. Patients and Methods: We mapped patient-level data from SIDIAP to the OMOP CDM and we performed more than 3,400 data quality checks to assess its readiness for research. We established a general population cohort as of the 1 st March 2020 and identified outpatient COVID-19 diagnoses or tested positive for, hospitalised with, admitted to intensive care units (ICU) with, died with, or vaccinated against COVID-19 up to 30th June 2022. Results: After verifying the high quality of the transformed dataset, we included 5,870,274 individuals in the general population cohort. Of those, 604,472 had either an outpatient COVID-19 diagnosis or positive test result, 58,991 had a hospitalisation, 5,642 had an ICU admission, and 11,233 died with COVID-19. A total of 4,584,515 received a COVID-19 vaccine. People who were hospitalised or died were more commonly older, male, and with more comorbidities. Those admitted to ICU with COVID-19 were generally younger and more often male than those hospitalised and those who died. Conclusion: We successfully transformed SIDIAP to the OMOP CDM. From this dataset, a general population cohort of 5.9 million individuals was identified and their COVID-19-related outcomes over time were described. The transformed SIDIAP database is a valuable resource that can enable distributed network research in COVID-19 and beyond. Keywords: electronic health records, medical ontologies, secondary data use, common data model, OMOP