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El análisis de un patrón puntual engloba una serie de técnicas que permiten estudiar la distribución de un conjunto de eventos ocurridos sobre una región del plano. Este problema surge en epidemiología cuando se investiga una potencial fuente de contaminación ambiental alrededor de la cual se sospecha que surgen casos de una determinada enfermedad. En el presente trabajo, se explica brevemente en qué consiste el análisis de un patrón puntual y se ilustra con una aplicación a la determinación del origen medioambiental y al estudio de las zonas de mayor riesgo de incidencia en un brote de neumonía por Legionella ocurrido entre mediados de septiembre y principios de octubre en la ciudad de Alcoi (Alicante). El estudio permitió confirmar el origen medioambiental del brote y señalar las zonas de la ciudad con mayor riesgo, convirtiéndose en el argumento básico para llevar a cabo una exhaustiva inspección de las instalaciones generadoras de aerosoles, tras la cual, hasta la fecha, cesaron los brotes epidémicos.

Objetivo: Valorar la descripción geoestadística realizada de los datos de gripe recogidos a través de la Red Centinela Sanitaria de la Comunidad Valenciana (RCSCV) mediante la utilización del método kriging con la finalidad de evaluar la posibilidad de su incorporación a la vigilancia rutinaria Método: Se han utilizado los datos de vigilancia de gripe de la RCSCV en tres temporadas gripales (1997-1998, 1998-1999 y 1999-2000), construyéndose una matriz de datos de incidencia de gripe geocodificada. La distribución geográfica fue estudiada mediante la técnica geoestadística kriging, que permite estimar la incidencia de la enfermedad en cualquier punto del territorio, a partir de la incidencia observada en unos pocos puntos estratégicamente distribuidos. Se elaboraron mapas de curvas de isoincidencia de gripe para cada semana. La valoración de la técnica se realizó mediante validación cruzada. Resultados: En la mayoría de las semanas, los valores tanto de la desviación estándar (DE) reducida, como de la media reducida estuvieron cercanos a los valores considerados óptimos (0 o 1, respectivamente), y sólo en la última temporada se obtuvieron valores de la DE reducida alejados de los considerados como de buen ajuste en 12 de las 20 semanas. La estimación de tasas en todas las temporadas demostró una coherencia en su distribución espacial. También se observó coherencia en la evolución temporal. Conclusiones: En la mayoría de las situaciones los resultados pueden considerarse aceptables, no requiere recursos informáticos extraordinarios ni un empleo de tiempo excesivo, y necesita tan sólo una adaptación anual. Su facilidad de uso lo hace apto para su utilización como una técnica de rutina, pese a que puede mejorarse la precisión de las estimaciones, incrementando la complejidad del modelo.

Objective: To evaluate spatial variation in exposure to nitrogen dioxide (NO2) air pollution in the city of Valencia, Spain, and its association with socioeconomic deprivation and age., Methods: Census tract population data were obtained from the National Statistics Institute of Spain. Outdoor NO2 was monitored in 100 sites in the study area, through the use of passive samplers, in three campaigns between 2002 and April 2004. Land use regression (LUR) was used to obtain a map of NO2 levels. The LUR predictions were compared with the NO2 level obtained by: a) the nearest sampler of the monitoring network, b) the nearest passive sampler, c) the mean distance-weighted levels of the samplers in the neighborhood, and d) the NO2 level obtained by using Kriging. For each census tract, the NO2 levels were obtained. The association of NO2 air pollution exposure with population age (≥65 years) and the 5-category deprivation index was analyzed., Results: The LUR models showed less error than the other prediction methods. The safety levels proposed by the World Health Organization were exceeded in more than 99% of the population. An inverse relationship was found between NO2 levels and the deprivation index (β = -2.01μg/m(3) in the most deprived quintile compared with lower deprivation, 95%CI: -3.07; -0.95) and a direct relationship was found with age (β = 0.12μg/m(3) per unit increase in percentage of the population ≥ 65 years, 95%CI: 0.08; 0.16)., Conclusions: The method allowed pollution maps to be obtained and the association between NO2 levels and sociodemographic characteristics to be described., (Copyright © 2011 SESPAS. Published by Elsevier Espana. All rights reserved.)

Objectives: To estimate the proportion of people requiring palliative and support care at home in primary care and to describe their characteristics., Methods: A descriptive study was carried out by five Spanish sentinel networks between October 2007 and March 2008 in 282,216 people attended by 218 general practitioners and nurses. Patients receiving comprehensive, active and continued care at home were included if the aim was not to prolong life but to achieve the best quality of life for the patient, the family and the carers. A standard form was used to collect data on age, sex, type of patient, underlying diseases and other variables related to the process. Crude and age-adjusted rates were estimated., Results: Of the 400 men and 792 women registered, 12% were strictly terminal. The mean age was 82.4 years and was higher in patients with functional disability (82.9 years) than in terminally-ill patients (78.9 years) (p<0.01). The estimated prevalence was 422.3 per 100,000 inhabitants aged 14 years or more (95% CI: 398.7-447.0) and was much higher in women than in men (553.9 versus 287.3, p<0.01). The estimate for the entire Spanish population was 309.0 per 100,000 inhabitants (95% CI: 286.0-332.0)., Conclusions: The prevalence of palliative and support care in Spain is around three cases per 1,000 inhabitants and is higher in elderly populations. More than 85% of patients needing palliative or support care have a life expectancy of over 6 months and thus represent the majority of persons using this type of medical and social support. The most susceptible groups are women and the oldest-old., (Copyright © 2010 SESPAS. Published by Elsevier Espana. All rights reserved.)

The objective of SESPAS Report 2010 is to enhance the incorporation of the principle of Health in all Policies in public health in Spain. The fundamental principle behind this slogan is very simple: Health is strongly influenced by the environment, how we live, work, eat, walk or enjoy our leisure time. Moreover, these living conditions depend not only on individual decisions but are determined by social, cultural, economic or environmental factor. Consequently, policy decisions that influence the health of people not just those related to services or health policy, but primarily those taken in other public, private, political and civic contexts. SESPAS Report 2010 has four parts. It begins with and introductory chapter on the challenges of incorporating the principle of Health in all Policies in public health. The second part consists of several articles of reflection on the relationship between the health care system and public health. The third part focuses on cross-sectoral public health policies. The report ends with several articles on cross-cutting issues such as public health education, information, research, evaluation and ethics in public health policies., (Copyright © 2010 SESPAS. Published by Elsevier Espana. All rights reserved.)

Objectives: To determine the prevalence of teenage maternity, preterm birth and low birth weight in Spanish and immigrant mothers from Latin America, eastern Europe, Maghreb and sub-Saharan Africa resident in Catalonia and Valencia from 2005 and 2006., Methods: Using data from congenital metabolic disorders registers in both regions, proportions and 95% confidence intervals were obtained for the following: 1) mothers aged less than 20 years; 2) preterm (<37 weeks) and very preterm (<32 weeks) births; and 3) low birth weight (<2500g) and very low birth weight (<1500g) neonates. The calculations were performed for mothers from each of the geographical areas of origin (Spain, Latin America, Eastern Europe, Maghreb and Sub-Sahara). These proportions were compared in Spanish-born and immigrant women and the significance of differences was assessed using chi-squared tests., Results: The prevalence of teenage mothers was between three and five times higher in immigrants than in Spanish women, the highest rate being found in women from eastern Europe. Preterm births, very preterm births and very low birth weight were more frequent in eastern European women than in Spanish women. The prevalence of prematurity and very low birth weight was higher in sub-Saharan mothers than in Spanish women., Conclusions: The number of births in teenage mothers was higher in immigrant mothers from all origins than in Spanish women. The highest rates of low birth weight and preterm births were found in women from eastern Europe and sub-Saharan Africa., (Copyright (c) 2009 SESPAS. Published by Elsevier Espana. All rights reserved.)

Objective: To assess the quality of data on births in the Natural Population Movement (NPM) and congenital metabolic disorders registers with regard to calculation of reproductive and perinatal health indicators., Methods: The following comparisons between registers were made: (1) the total number of births to mothers living in Catalonia and Valencia from 2005 to 2006, (2) the percentage of missing data on the mother's geographical origin, (3) the percentage of missing data on the mother's age and the infant's birthweight and gestational age according to maternal origin., Results: The congenital metabolic disorders registers exhaustively collected the total number of births gathered in the NPM. The percentages of missing data on material origin and age were higher in the congenital metabolic disorders registers, although the proportion of births by maternal origin and the mean maternal age in each ethnic group was fairly similar to that in the NPM. The percentages of missing data on birthweight and gestational age were much higher in the NPM data than in the congenital metabolic disorders registers, especially among births registered in Catalonia and births to foreign mothers., Conclusions: Our results suggest some limitations in the quality of the data on gestational age and birthweight provided by NPM data, especially for comparisons of preterm and low birthweight indicators in the Spanish-born and immigrant populations. Moreover, the results point to the quality of the congenital metabolic disorders registers as a source to compare reproductive and perinatal health indicators., (Copyright (c) 2009 SESPAS. Published by Elsevier Espana. All rights reserved.)

Background: Social vulnerability implies a higher risk of induced abortion (IA). Immigrant status could be an additional factor. The objective was to identify the patterns surrounding which women resort to IAs, and to study the relationship between socio-economic and health system factors. Another aim was to determine the relationship between the patterns identified and the immigrant's country., Methods: A cross-sectional study was performed including all IAs notified during 2006 on women residing in three Spanish autonomous communities (the Balearic Islands, Catalonia and Comunitat Valenciana). We used sociodemographic, nationality and related variables, reproductive history and use of health services. A Categorical Principal Component Analysis was used to summarize the information and to identify profiles., Results: More than a third of IAs were performed on non-Spanish women. Four dimensions have been determined that define the profile of women resorting to IAs: age, reproductive history and marital status; type of health services used; social level; and earlier or late IA and its repetitive use. Age and related factors were important determinants. Economic status and knowledge of the health system were related to access to contraception and IA information. Spanish, Western European and South American women had a higher social level than Romanian and African women. Late IA use and a lower recurrence characterised Asian, North African and Spanish women., Conclusion: Differences on IA use between groups of different women seem to be related to vulnerability (economic, social, knowledge and use of healthcare services). There is a different situation among immigrants of differing nationalities.

Objectives: To analyze time trends and the geographical distribution of avoidable mortality in the autonomous community of Valencia and its health departments by sex in the periods 1990-1994, 1995-1999, and 2000-2004., Material and Method: Twenty-one causes of avoidable mortality were analyzed. The deaths analyzed corresponded to residents in the autonomous community of Valencia between 1990 and 2004. Age-standardized mortality rates were calculated using the direct method. To study time trends in the geographical area of interest for each period and sex, comparative mortality ratios were calculated. To analyze geographical distribution, standardized mortality rates were calculated by the indirect method., Results: The total number of avoidable deaths was 38,061 (7.1% of overall deaths). Men accounted for 76.2% and women for 23.8%. By groups, 82.4% were preventable and 17.6% were treatable. Preventable deaths represented 86.5% of deaths in men and 69.4% of those in women. Avoidable mortality in Valencia significantly decreased in both sexes, this decrease being more marked in the group of treatable deaths and in men. Mortality from lung cancer in women significantly increased. Between 2000 and 2004, none of the health departments showed a significant excess of treatable mortality., Conclusions: In the autonomous community of Valencia, there was a greater decrease in avoidable mortality than in general mortality. The increase in lung cancer in women was notable.

Point pattern analysis pattern comprises a series of techniques that enables the distribution of a series of events occurring in the vicinity of a particular region of a map to be studied. In epidemiology, this problem arises when a potential source of environmental contamination, possibly leading to cases of a specific disease, is investigated.The present study provides a brief description of point pattern analysis. The approach is illustrated through determination of the environmental source and study of the areas of greatest risk of incidence of an outbreak of legionella pneumonia that occurred between the middle of September and beginning of October in the city of Alcoi in Alicante (Spain).Point pattern analysis was able to confirm the environmental source of the outbreak and identify the areas of the city at greatest risk. This provided the justification for an exhaustive inspection of the installations generating aerosols after which, to date, the epidemics ceased.

Objectives: To evaluate geostatistical description of influenza data from the Valencian Sentinel Network (VSN) in Spain using the kringing method and to assess the possibility of incorporating this method into routine surveillance., Methods: We use influenza surveillance data on three influenza seasons (1997-1998, 1998-1999 and 1999-2000) from the VSN to construct a geocodified data matrix of the incidence of this disease. The geographic distribution was studied using the kringing method, which enables estimation of the incidence in a few strategically distributed points. Influenza isoincidence maps for each week were plotted. Cross validation was used to evaluate the method., Results: In most of the weeks, the values of reduced standard deviation and reduced mean were close to the optimal values (0 and 1, respectively). Out of range reduced standard deviation values were found in 12 of 20 weeks in the last season only. The estimation of rates in all three seasons showed coherence in spatial distribution and temporal evolution., Conclusions: In most situations the results were acceptable. The method does not require extra computer resources or an excessive amount of time and requires only annual adaptation. Because it is easy to use, the technique is appropriate for routine use but the accuracy of estimations could be improved by increasing the complexity of the model.

We present a pilot experience about the introduction of a information system designed for the knowledge of infant morbidity (4-15 years) in a 13 school week period in a representative sample of 60 schools of the Valencian Community. We studied school absences that lasted three days or longer. Reports of teachers and parents were the source of information (100% response rate). Medical certification was also requested to the pediatricians and general practitioners of the area of the schools (12.74% response rate). To test the validity of this information system, absences caused by hepatitis were compared with the registry of Notifiable Diseases System (NDS) for the same period. We recorded 3,968 absences, with a cumulative incidence of 100.68 per 1,000 (C.I., alpha = .05, +/- 4.97) for females, and 119.4 (C.I., alpha = .05, +/- 18.36) for males. These differences were statistically significant. There was a concordance of 80.25% of the hepatitis cases between the registry of absenteeism and that of the NDS (chi 2 goodness of fit test = 3.16, p = .754). Although absences shorter than 3 days were not taken into account, the information system provided relevant and valid estimates of morbidity. Moreover, collaboration of teachers was considered very positive, which led us to use this health information system in five health areas of the Valencian Community.