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Human mobility drives the geographical diffusion of infectious diseases at different scales, but few studies focus on mobility itself. Using publicly available data from Spain, we define a Mobility Matrix that captures constant flows between provinces by using a distance-like measure of effective distance to build a network model with the 52 provinces and 135 relevant edges. Madrid, Valladolid and Araba/Álaba are the most relevant nodes in terms of degree and strength. The shortest routes (most likely path between two points) between all provinces are calculated. A total of 7 mobility communities were found with a modularity of 63%, and a relationship was established with a cumulative incidence of COVID-19 in 14 days (CI14) during the study period. In conclusion, mobility patterns in Spain are governed by a small number of high-flow connections that remain constant in time and seem unaffected by seasonality or restrictions. Most of the travels happen within communities that do not completely represent political borders, and a wave-like spreading pattern with occasional long-distance jumps (small-world properties) can be identified. This information can be incorporated into preparedness and response plans targeting locations that are at risk of contagion preventively, underscoring the importance of coordination between administrations when addressing health emergencies. This research has been financed by Carlos III Health Institute (ISCIII) under the project COV20-00881 and the project Fundación BBVA.DGVI 256/22 “COVID-19 Urban Atlas Spain”. Sí

Background: Several environmental factors seem to be involved in childhood leukaemia incidence. Traffic exposure could increase the risk while urban green spaces (UGS) exposure could reduce it. However, there is no evidence how these two factors interact on this infant pathology. Objectives: to evaluate how residential proximity to UGS could be an environmental protective factor against traffic exposure on childhood leukaemia incidence. Methods: A population-based case control study was conducted across thirty Spanish regions during the period 2000–2018. It included 2526 incident cases and 15,156, individually matched by sex, year-of-birth, and place-of-residence. Using the geographical coordinates of the participants’ home residences, a 500 m proxy for exposure to UGS was built. Annual average daily traffic (AADT) was estimated for all types of roads 100 m near the children’s residence. Odds ratios (ORs) and 95% confidence intervals (95% CIs), UGS, traffic exposure, and their possible interactions were calculated for overall childhood leukaemia, and the acute lymphoblastic (ALL) and acute myeloblastic leukaemia (AML) subtypes, with adjustment for socio-demographic covariates. Results: We found an increment of childhood leukaemia incidence related to traffic exposure, for every 100 AADT increase the incidence raised 1.1% (95% CI: 0.58–1.61%). UGS exposure showed an incidence reduction for the highest exposure level, Q5 (OR = 0.63; 95% CI = 0.54–0.72). Regression models with both traffic exposure and UGS exposure variables showed similar results but the interaction was not significant. Conclusions: Despite their opposite effects on childhood leukaemia incidence individually, our results do not suggest a possible interaction between both exposures. This is the first study about the interaction of these two environmental factors; consequently, it is necessary to continue taking into account more individualized data and other possible environmental risk factors involved.

Air pollution is considered an ongoing major public health and environmental issue around the globe, affecting the most vulnerable, such as pregnant women and fetuses. The aim of this study is to estimate the health impact and economic value on birth outcomes, such as low birthweight (LBW), preterm birth (PTB), small for gestational age (SGA), attributable to a reduction of PM10 levels in Spain. Reduction based on four scenarios was implemented: fulfillment of WHO guidelines and EU limits, and an attributable reduction of 15% and 50% in annual PM10 levels. Retrospective study on 288,229 live-born singleton children born between 2009–2010, using data from Spain Birth Registry Statistics database, as well as mean PM10 mass concentrations. Our finding showed that a decrease in annual exposure to PM10 appears to be associated with a decrease in the annual cases of LBW, SGA and PTB, as well as a reduction in hospital cost attributed to been born with LBW. Improving pregnancy outcomes by reducing the number of LBW up to 5% per year, will result in an estimate associated monetary saving of 50,000 to 7,000,000 euros annually. This study agrees with previous literature and highlights the need to implement, and ensure compliance with, stricter policies that regulate the maximum exposure to outdoor PM permitted in Spain, contributing to decreased environmental health risk, especially negative birth outcomes.

Childhood and adolescent cancer survivors (CACS) are a high-risk population for non-communicable diseases and secondary carcinogenesis. The Environmental and Community Health Program for Longitudinal Follow-up of CACS in the region of Murcia, Spain, is an ongoing pioneering program that constitutes a model for social innovation. This study aims to present the program tools and protocol as a whole, as well as a profile of the incidence, survival, and spatiotemporal distribution of childhood cancer in the region of Murcia, Spain, using 822 sample cases of cancer diagnosed in children under 15 years of age (1998-2020). While the crude incidence rate across that entire period was 149.6 per 1 million, there was an increase over that time in the incidence. The areas with a higher standardized incidence ratio have shifted from the northwest (1998-2003) to the southeast (2016-2020) region. Overall, the ten-year survival rate for all tumor types was 80.1% over the entire period, increasing the five-year survival rate from 76.1 (1998-2003) to 85.5 (2014-2018). CACS living in areas with very poor outdoor air quality had lower survival rates. Furthermore, integrating environmental health into clinical practice could improve knowledge of the etiology and prognosis, as well as the outcomes of CACS. Finally, monitoring individual carbon footprints and creating healthier lifestyles, alongside healthier environments for CACS, could promote wellbeing, environmental awareness, and empowerment in order to attain Sustainable Development Goals for non-communicable diseases in this population. This research was supported by the Environment, Survival and Childhood Cancer Project, Spanish Federation of Parents of Children with Cancer (FFIS-CCE-2019-11); Environmental Health Profile for Children Project funded by Sociedad Pediatria Sureste Esp. (FFIS-DF-2022-36); the International Network of Environment, Survival and Childhood Cancer (ENSUCHICA) in Europe and Latin America (FFIS EU17-01-01); Fundación Científica de la AECC (MACAPE-2004); Medio Ambiente Cáncer Pediátrica en la Región De Murcia (MACAPEMUR-2009 ~FFIS/EMER09/15); the Mount Sinai International Exchange Program for Minority Students funded by the National Institute of Minority Health and Health Disparities (T37 MD001452); and the International Training and Research Program in Environmental and Occupational Health funded by the Fogarty International Center, United States (TW00640). The funders had no role in the completion of the research project, the writing of the manuscript for publication, or the decision to publish the results. Sí

The variation on birth weight is associated with several outcomes early on in life and low birth weight (LBW) increases the risk of morbidity and mortality. Some environmental exposures during pregnancy, such as particulate matters and other traffic-related pollutants can have a significant effect on pregnant women and fetuses. The aim of this study is to estimate the effect of exposure to traffic density during pregnancy over birth weight in Spain, from 2000-2017. This was a retrospective, cross-sectional study using the information from Spain Birth Registry Statistics database. The traffic density was measured using the Annual average daily traffic. Multivariate linear regression models using birth weight and traffic density were performed, as well as a logistic regression model to estimated Odds ratios for LBW and GAM models to evaluate the non-linear effect. Our findings showed that increases in traffic density were associated with reduction of birth weight and increases of LBW risk. Moreover, exposure to high and very-high traffic-density during pregnancy were associated with reduction of birth weight and increase on LBW risk comparing with exposure to low number of cars trespassing the neighborhoods. The results of this study agree with previous literature and highlights the need of effective policies for reducing traffic density in residential neighborhoods of cities and towns. This work was supported by the Spanish Consortium for Research on Epidemiology and Public Health(CIBERESP) (ESP20PI01/2020) and Spanish Institute of Health Carlos III (PI19CIII-00025. Mònica Guxens is funded by a Miguel Servet II fellowship (CPII18/00018) awarded by the Spanish Institute of Health Carlos III. We also acknowledge support from the Spanish Ministry of Science and Innovation and the State Research Agency through the “Centro de Excelencia Severo Ochoa 2019-2023” Program (CEX2018-000806-S), and support from the Generalitat de Catalunya through the CERCA Program. Sí

Background After a national lockdown during the first wave of the COVID-19 pandemic in Spain, regional governments implemented different non-pharmaceutical interventions (NPIs) during the second wave. Aim To analyse which implemented NPIs significantly impacted effective reproduction number (Rt) in seven Spanish provinces during 30 August 2020–31 January 2021. Methods We coded each NPI and levels of stringency with a ‘severity index’ (SI) and computed a global SI (mean of SIs per six included interventions). We performed a Bayesian change point analysis on the Rt curve of each province to identify possible associations with global SI variations. We fitted and compared several generalised additive models using multimodel inference, to quantify the statistical effect on Rt of the global SI (stringency) and the individual SIs (separate effect of NPIs). Results The global SI had a significant lowering effect on the Rt (mean: 0.16 ± 0.05 units for full stringency). Mandatory closing times for non-essential businesses, limited gatherings, and restricted outdoors seating capacities (negative) as well as curfews (positive) were the only NPIs with a significant effect. Regional mobility restrictions and limited indoors seating capacity showed no effect. Our results were consistent with a 1- to 3-week-delayed Rt as a response variable. Conclusion While response measures implemented during the second COVID-19 wave contributed substantially to a decreased reproduction number, the effectiveness of measures varied considerably. Our findings should be considered for future interventions, as social and economic consequences could be minimised by considering only measures proven effective.

The authors acknowledge the support of the research grants PI16/00670, PI16/00755, PI16/01004, PI16/01187, PI16/01273, PI16/01281, and PI18/01313 of Instituto de Salud Carlos III, co-funded with FEDER grants., Martinez-Beneito, M.A., Vergara-Hernández, C., Botella-Rocamora, P., Corpas-Burgos, F., Pérez-Panadés, J., Zurriaga, Ó., Aldasoro, E., Borrell, C., Cabeza, E., Cirera, L., Osinaga, J.D., Fernández-Somoano, A., Gandarillas, A., Lorenzo Ruano, P.L., Marí-Dell’olmo, M., Nolasco, A., Prieto-Salceda, M.D., Ramis, R., Rodríguez-Sanz, M., Sánchez-Villegas, P.

The province of Cadiz, Spain, is a highly industrialized area with numerous registered industrial plants, which has led to major concern regarding the possible influence of these facilities on the high rate of cancer-related mortality observed. Our objective was to evaluate the association between digestive cancer mortality and proximity to industrial installations in the province of Cadiz over the period 1992-2014 and to analyse this risk according to different categories of carcinogenic substances. An ecological study at the census tract level was carried out. Mortality due to digestive cancer (involving the oral cavity, pharynx, oesophagus, stomach, liver, pancreas, gallbladder, colon and rectum) was analysed. Using the spatial Besag, York and Mollié (BYM) approach, we assessed the relative risk of dying from these cancers for people living between 500 m and 5 km from industrial installations. The models were adjusted to account for socioeconomic deprivation. We detected a significant, excess risk of dying due to cancer in the following organs (expressed as relative risk with 95% confidence intervals): colon/rectum (1.13; 1.04-1.22 at 4 km), stomach (1.13; 1.00-1.29 at 2 km), liver (1.28; 1.02-1.61 at 1 km), pancreas (1.19; 1.03-1.39 at 2 km), oral and pharyngeal (1.40; 1.08-1.82 at 1 km), oesophagus (2.05; 1.18-3.56 at 500 m) and gallbladder (2.80; 1.14-6.89 at 500 m) for men; and from colorectal (1.21; 1.00-1.46 at 1 km), stomach (1.15; 1.01-1.31 at 4 km) and liver (1.58; 1.20- 2.07 at 1 km) cancers for women. The results support the hypothesis of an association between several digestive cancers and proximity to polluting industrial plants. Funding: This work was supported by the LONGPOP (Methodologies and Data Mining Techniques for the Analysis of Big Data Based on longitudinal Population and Epidemiological Registers) project, which has received funding from the European Union’s Horizon 2020 research and innovation program under the Marie Sklodowska-Curie grant 676060. JG-P was funded by the Scientific Foundation of the Spanish Association Against Cancer (Fundación Científica de la Asociación Española Contra el Cáncer (AECC) – EVP-1178/14). Sí

Residential proximity to industrial facilities that release pollutants is a source of exposure to a high number of toxics, many of them known or suspected carcinogens. The objective of the study was to analyze the association between lung, larynx, bladder, and kidney cancer mortality and deprivation in areas proximate to polluting industrial facilities in Cadiz, a highly industrialized province in Spain. An ecological study at census tract level was carried out to estimate the mortality rates associated with deprivation and proximity to polluting industrial facilities (1&ndash, 5 km) using the Besag&ndash, York&ndash, Molli&eacute, model. The results show a negative social gradient for lung and larynx cancers in males and greater risk of lung cancer was observed in the least deprived areas in females. These associations were found regardless the distance to industrial facilities. Increasing excess risk (relative risk, 95% credibility interval) of lung cancer for males (1.09, 1.02&ndash, 1.16 at 5 km vs 1.24, 1.08&ndash, 1.41 at 1 km) and bladder cancer for males (1.11, 1.01&ndash, 1.22 at 5 km vs 1.32, 1.60 at 1 km) and females (1.32, 1.04&ndash, 1.69 at 4 km vs 1.91, 1.28&ndash, 2.86 at 1 km) was found as proximity to polluting industrial facilities increased. For kidney cancer, high risks were observed near such facilities for both sexes. Knowing the possible influence of industrial pollution and social inequalities over cancer risk allows the definition of policies aimed at reducing the risk.

Maternal alcohol consumption during pregnancy is responsible for negative health outcomes. The literature shows that socio-economic and lifestyle factors are both related with alcohol consumption during pregnancy; nevertheless, the role of other factors is unclear. The objective of this study is to assess the role that partners' alcohol consumption plays, that played by accessibility to alcohol, and by social influence - when considering pregnant women's behaviour as regards alcohol. It presents the results from a follow-up study of children at risk of negative health outcomes associated with prenatal alcohol exposure; it shows that 68% of pregnant women included in the study reported alcohol consumption during early pregnancy. Results of the analysis showed association with partners' alcohol use, with density of bars and/or restaurants and with the number of pregnant women who drank in the neighbourhood. We concluded that the involvement of men in pregnancy healthcare, and urban policies which target the built environment and improve social networks could be important aspects for the control and prevention alcohol consumption during pregnancy in public health programs. Interventions and recommendations should include an ecological perspective on prenatal community-health programs - focusing on individual, social, and natural factors as well as the built environment. The authors gratefully acknowledge the project “Nacer y Crecer sin OH” (PND 2016. Murcia’s Drug Commissioner Office and the National Plan on Drugs, Ministry of Health, Spain. Prof. Fernando A. López-Hernández, is also grateful for the financial support provided by the projects from the Programa de Ayudas a Grupos de Excelencia de la Región de Murcia, Fundación Séneca(#19884-GERM-15). The views expressed are those of the authors and not necessarily those of the Carlos III Institute of Health. Sí

BACKGROUND: Environmental exposures are related to the risk of some types of cancer, and children are the most vulnerable group of people. This study seeks to present the methodological approaches used in the papers of our group about risk of childhood cancers in the vicinity of pollution sources (industrial and urban sites). A population-based case-control study of incident childhood cancers in Spain and their relationship with residential proximity to industrial and urban areas was designed. Two methodological approaches using mixed multiple unconditional logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) were developed: (a) "near vs. far" analysis, where possible excess risks of cancers in children living near ("near") versus those living far ("far") from industrial and urban areas were assessed; and (b) "risk gradient" analysis, where the risk gradient in the vicinity of industries was assessed. For each one of the two approaches, three strategies of analysis were implemented: "joint", "stratified", and "individualized" analysis. Incident cases were obtained from the Spanish Registry of Childhood Cancer (between 1996 and 2011). RESULTS: Applying this methodology, associations between proximity (≤ 2 km) to specific industrial and urban zones and risk (OR; 95% CI) of leukemias (1.31; 1.04-1.65 for industrial areas, and 1.28; 1.00-1.53 for urban areas), neuroblastoma (2.12; 1.18-3.83 for both industrial and urban areas), and renal (2.02; 1.16-3.52 for industrial areas) and bone (4.02; 1.73-9.34 for urban areas) tumors have been suggested. CONCLUSIONS: The two methodological approaches were used as a very useful and flexible tool to analyze the excess risk of childhood cancers in the vicinity of industrial and urban areas, which can be extrapolated and generalized to other cancers and chronic diseases, and adapted to other types of pollution sources. This study was funded by Carlos III Institute of Health, Spain Grand EPY1344/16, Spain’s Health Research Fund (Fondo de Investigación Sanitaria—FIS 12/01416), and Scientific Foundation of the Spanish Association Against Cancer, Spain (Fundación Científica de la Asociación Española Contra el Cáncer (AECC)—EVP-1178/14). This article presents independent research. The views expressed are those of the authors and not necessarily those of the Carlos III Institute of Health. Sí

BACKGROUND: Current evidence suggests that childhood leukaemia can be associated with residential traffic exposure; nevertheless, more results are needed to support this conclusion. OBJECTIVES: To ascertain the possible effects of residential proximity to road traffic on childhood leukaemia, taking into account traffic density, road proximity and the type of leukaemia (acute lymphoid leukaemia or acute myeloid leukaemia). METHODS: We conducted a population-based case-control study of childhood leukaemia in Spain, covering the period 1990-2011. It included 1061 incidence cases gathered from the Spanish National Childhood Cancer Registry and those Autonomous Regions with 100% coverage, and 6447 controls, individually matched by year of birth, sex and autonomous region of residence. Distances were computed from the respective participant's residential locations to the different types of roads and four different buffers. Using logistic regression, odds ratios (ORs) and 95% confidence intervals (95%CIs), were calculated for four different categories of distance to roads. RESULTS: Cases of childhood leukaemia had more than three-fold increased odds of living at

Cancer can be caused by exposure to air pollution released by industrial facilities. The European Pollutant Release and Transfer Register (E-PRTR) has made it possible to study exposure to industrial pollution. This study seeks to describe the industrial emissions in the vicinity of Spanish towns and their temporal changes, and review our experience studying industrial pollution and cancer. Data on industrial pollutant sources (2007-2010) were obtained from the E-PRTR registries. Population exposure was estimated by the distance from towns to industrial facilities. We calculated the amount of carcinogens emitted into the air in the proximity (

FI=6.248 (año 2012), D1 Background: Population exposure to emissions from multiple industrial sources, though little studied, is an aspect of great interest from an epidemiologic standpoint. Objectives: To investigate whether risk of dying due to tumors of the digestive system in populations residing in the vicinity of Spanish metal production and processing installations increases with proximity to a greater number of industrial facilities. Methods: An ecologic study was designed to ascertain municipal mortality due to malignant tumors of the digestive system (oral cavity and pharynx, esophagus, stomach, pancreas, liver, gallbladder and colon-rectum) during the period 1994-2003, in Spanish regions with the presence of multiple industrial sources in the metal sector. Population exposure to pollution was estimated on the basis of distance from town of residence to pollution source. Using Poisson regression models, we analyzed: the increased risk of dying of cancer with proximity to a given number of sources; and excess mortality in the vicinity of specific industrial clusters. Results: The tumor responsible for the greatest number of regions with increased risk in both sexes was liver cancer (78% of the regions, being statistically significant in Valencia (p-value for trend (p trend)=0.001 in both sexes), Madrid (p trend=0.011 in women) and the Basque Country (p trend=0.002 in men)), followed by colorectal and pancreatic cancers (56% of the regions, being statistically significant in both sexes in Valencia (p trend=0.001) and Zaragoza (p trend=0.018) for colorectal cancer; and Valladolid (p trend=0.019 in men) and Barcelona (p trend=0.049 in women) for pancreatic cancer). Valencia was the province that displayed increased risk with the proximity to metal industries for all tumors studied, while the Basque Country was the Autonomous Region that registered a rising risk trend for liver, stomach and colorectal tumors with proximity (≤5 km) to a greater number of sources. Conclusions: The results could support the hypothesis that mortality due to certain tumors of the digestive system increases with proximity (≤5 km) to a greater number of metal industry sources. Nevertheless, in this type of ecologic study, conclusions cannot be obtained in terms of cause and effect, nor can individual inferences be made from grouped data. This study was funded by Spain's Health Research Fund (Fondo de Investigación Sanitaria - FIS 040041) and formed part of the MEDEA project (Mortalidad en áreas pequeñas Españolas y Desigualdades socio-Económicas y Ambientales - Mortality in small Spanish areas and socio-economic and environmental inequalities). No

Background: Prostate cancer is the second most common type of cancer among men but its aetiology is still largely unknown. Different studies have proposed several risk factors such as ethnic origin, age, genetic factors, hormonal factors, diet and insulin-like growth factor, but the spatial distribution of the disease suggests that other environmental factors are involved. This paper studies the spatial distribution of prostate cancer mortality in an industrialized area using distances from each of a number of industrial facilities as indirect measures of exposure to industrial pollution. Materials and methods: We studied the Gran Bilbao area (Spain) with a population of 791,519 inhabitants distributed in 657 census tracts. There were 20 industrial facilities within the area, 8 of them in the central axis of the region. We analysed prostate cancer mortality during the period 1996–2003. There were 883 deaths giving a crude rate of 14 per 100,000 inhabitants.We extended the standard Poisson regression model by the inclusion of a multiplicative non-linear function to model the effect of distance from an industrial facility. The function's shape combined an elevated risk close to the source with a neutral effect at large distance. We also included socio-demographic covariates in the model to control potential confounding. Results: We aggregated the industrial facilities by sector: metal, mineral, chemical and other activities. Results relating to metal industries showed a significantly elevated risk by a factor of approximately 1.4 in the immediate vicinity, decaying with distance to a value of 1.08 at 12 km. The remaining sectors did not show a statistically significant excess of risk at the source. Discussion: Notwithstanding the limitations of this kind of study, we found evidence of association between the spatial distribution of prostate cancer mortality aggregated by census tracts and proximity to metal industrial facilities located within the area, after adjusting for socio-demographic characteristics at municipality level. Keywords: Prostate cancer, Environmental exposure, Industrial pollution, Metal industry, Non-linear model

The study was partially funded by the “Accion Transversal del Cancer”, approved on the Spanish Ministry Council on the 11th October 2007, by the Instituto de Salud Carlos III-FEDER (PI08/1770, PI08/0533, PI08/1359, PS09/00773, PS09/01286,PS09/01903, PS09/02078, PS09/01662, PI11/01403, PI11/01889,PI11/00226, PI11/01810, PI11/02213, PI12/00488, PI12/00265,PI12/01270, PI12/00715, PI12/00150), Castaño-Vinyals, G., Aragonés, N., Pérez-Gómez, B., Martín, V., Llorca, J., Moreno, V., Altzibar, J.M., Ardanaz, E., de Sanjosé, S., Jiménez-Moleón, J.J., Tardón, A., Alguacil, J., Peiró, R., Marcos-Gragera, R., Navarro, C., Pollán, M., Kogevinas, M., Alonso, M.T., Amiano, P., Arias, C., Azpiri, M., Benavente, Y., Boldo, E., Bueno, A., Bustamante, M., Caballero, F.J., Campo, E., Cantón, R., Capelo, R., Carmona, C., Casabonne, D., Chirlaque, M.D., Cirac, J., Clofent, J., Colado, E., Costas, L., Crous, M., Del Campo, R., Santos, M.D., Dierssen-Sotos, T., Ederra, M., Espinosa, A., Cabrera, M.F., Somoano, A.F., Villa, T.F., García-Esquinas, E.G., Martín, P.G., Gómez-Acebo, I., Puga, C.G., Gràcia, E., Eslava, M.G., Guinó, E., Huerta, J.M., Lope, V., López-Abente, G., Lopez-Otín, C., Argüelles, B.M., Salas, S.M., Pozo, B.M., de la Torre, A.J., Moreno, E., Iribas, C.M., Olea, N., Gelis, G.O., Paré, L., Porta, M., Puig, M., Del Fresno, M.R., Robles, C., Suarez, M.M., Romero, B., Castillo, A.I., Serra, M.S., Trejo, D.S., Santaballa, A., Santibáñez, M., Sierra, Á., Souto, A., Villanueva, C.M., Carrasco, E., Sabaté, Y., Persavento, C., García, M., Carrasco, G., Expósito, A., Andreu, M., Bessa, X., Piracés, M., Lorente, J.A., Tusquets, I., Collet, I., Bory, F., Pera, M., Abella, E., Garcia, F., Salar, A., Piñol, M., Fernandez-Llamazares, J., Martín, M.V., Garsot, E., Servio, L.I., Arzoz-Fabregas, M., Suarez, L., Ruiz, J.M., Castells, A., Serradesanferm, A., Bosch, A., Muñoz, M., Fontanillas, M., Alcaraz, A., Mengual, L., Duran, E., Izard, C., López, C., Benítez, J.M., Massanes, A.B., Ferrer, O.G., Almeda, J., Sarret, S., Rodriguez, M.A., Valmaseda, A.B., Liceran, M., Petitbó, D., Nolla, J.I., Pérez, S., Martínez, S., Vilaseca, J.M., Sebastián, L., Quesada, P., Sequera, G., Barca, E.G., Domingo-Domenech, E., Oliveira, A., Alonso, E., de la Banda, E., Sabater, Y., Vergara, M., Exposito, A., Alonso, T., Padrol, I., Klaustermeier, J., Florencia, Y., Camon, V., Esteban, A., Aymerich, M., Lopez-Otin, C., Muñoz, A., Torralba, Y., Dot, D., Mercadal, S., Sarra, J., Medina, P., Atienza, C., Biondo, S., de Oca, J., Ferran, L., Rodriguez-Moranta, F., Soriano, A., Guardiola, J., Urruticoechea, A., Galan, M., Banda, J.M., Zumel, Á., Saez, A., Garrido, J.A., Lacasaña, M., Ariza, J.L., García, T., García, M.Á., Hidalgo, M.Á., Asuero, M., Bayo, J., Vázquez, V.C., Franco, F., Gurucelain, J.L., Frías, M.J., Van de Haar, R., Viñas, J., Jiménez, H., Aguayo, M., Pereira, A., Gutiérrez, S.P., Rada, R., Candón, J., Domínguez, J., Ramos, M., Pedraza, G., Braulio, J., Salas, J., Labrero, D., Muñoz, D., Barrero, F., Delgado, S., Galisteo, L., Camacho, A., Elena, H., Caballero, J., Muñoz, M.J., Arredondo, F., Linares, R., Tejada, A., Tinto, H., Alés, J.D., Coronado, M.V., Bernal, M.L., Ortiz, J.L., Ocaña, M.N., Cavanillas, A.B., Miguel, Mejías, E.J., Abril, O.M., Requena, R.O., Morata, J.L., Echezarreta, E.G., López, L.M., Martínez, M.M., Sedano, P.P., de la Pedraja Pavón, A., López-Rojo, C., Mendiola, J., Pellicer, E., Caparrós, J.M., Oltra, E.G., Martínez, J.M., Molina, A., Villanueva, V., Miranda, M.J., Abril, C., Martinez, J., Salas, D., Ruiz, J.L., Ponce, M., Noos, P., Cervera, J., Del Val, A., Segura, A., Jiménez, N., Bellmunt, E., Aznar, I., Ramos, D., Montón, T., Solera, M.C., Mora, E.M., Estañ, N., Camarasa, N., Solanas, J.V., Ripoll, J., Cantero, J., Díaz, C.A., García, A.S., Avellón, S.M., Neumann, M., González, M.J., Suárez, M.M., Fernández, G., Fresno, M.R., Gómez, A., Garín, U., de Gros, A., Tamayo, E., Rua, M., Lasarte, C.S., Jauregi, M., Recio, J., Fernández, M., Múgica, M., Ciria, J.P., Guimón, E., Adúriz, C., Lacasta, A., Francisco, J.S., Alvarez, I., Enriquez-Navascués, J.M., Ruiz, I., Michelena, M., Alberro, J.A., Almansa, A.M., Goñi, L.M., Elizagaray, M.I., Técnico, M.O., Pérez, R.B., De Miguel Medina, M.C., Repáraz Romero, M., de Azúa Ciria, A.Y., Díaz, M.M., Lizárraga, M.S., Jiménez, Y.L., López, C.E., Legaz, S.O., Lezaun, R.A., Hurtado, H.O., De Miguel Velasco, M., Rubio, P.A., Cunchillos, F.D., de Liaño Arguelles, Á.D., Peñuela, J.M., Dorronsoro, M.L., Celaya, F.B., García, D.R., de la Higuera Carnicer, B.G., Tricas, J.M., Rivera, E.M., García, F.V., Noain, J.J., Erdozain, E.A., Ulibarrena, C.I., Lopeandía, J.G., Caden, M.A., Moraza, F.A., Domench, J.J., Arteaga, A.A., Navarro, K.A., Del Burgo Tajadura, M.A., Irastorza, F.C., Urrisarri, M.J., Zubicoa, B.F., Lorente, P.G., Sevilla, P.H., Echamendi, M.L., Díaz, Á.M., Salaverri, J.M., Gorricho, F.J., Del Valle, M.P., de Prado Marcilla, J., Garcésducar, M., Herce, P.A., Barasoain, J.E., Campos, I.A., Vergara, E.A., Beraza, B.C., Blasco, L.F., Díaz, L.G., Larrañeta, J.G., Ruiz, N.G., García, J.G., Orduna, M.S., Larena, D.I., Fernández, M.P., de Ciriza Pejenaute, F.J., Escuin, R., Puertas, I.R., Samper, I.A., Sesma, M.E., López, M.J., Apestegui, C.Z., Linares, C., Cervantes, M., Ferreras, E., García-Pérez, J., Fernández-Navarro, P., Pastor, R., Ramis, R., González, Á., Ruiz, T., Muñoz, V., Delgado, R., Lanza, M., Marín, M., Posada, M., Cosmen, J., Villanueva, A., Castaño, A., Jiménez, J.A., Rin, A., Díaz, G., Herreros, M., Pedraza, V., López, P., de la Fuente, M., de Castro, M.F., Sobrino, J., Calvo, R., Carrascal, I., Bernal, R., Mateo, A., García-Olmo, D., Zarazaga, A., Gombau, M.Á., Díaz, J., Gómez, T., Sánchez, T., de la Quintana, P., Ordás, J., Cuevas, P., Sánchez-Pastor, M., de la Peña, J.J., Tabernero, Á., Cámara, N., Hardisson, D., Suárez, A., Burgos, E., Alves, J., Miguel, M., Feliú, J., Belda, C., Zamora, P., Sánchez, A., Hernández, A., Beato, T., Arroba, A., Ballesteros, A., Canora, S., García, C., Romero, M., José, T.S., Espinel, M., Mañas, A., Sánchez, M., Ramón, H., Morillo, J.L., Cuchí, M., García, M.J., Ramos, J.M., Rojo, R., Sanjuanbenito, A., Villanueva, A.G., Gras, M., Cabañas, J.L., Collado, V., Arano, I., Capela, I., Mojarrieta, C., Peñas, B., Rodríguez, M., Ramos, A., Sancho, S., Hervás, A., Moreno, P., Sánchez, C., DoloresRubio, Montoya, L., Sancho, P., Rodríguez, L., Durán, E., Morel, S., Burgos, J., García, R., Del Cañizo, C.G., Díaz, A., González, F., Cristóbal, E., Barahona, C., Vázquez, S., Esteban, V., Pedrera, M., Martínez, J., Carrato, A., Ponce, C.G., Santos-Olmo, A., Barrientos, R.R., López, G., Fernández, A., García, A.B., Noriega, A., Campo, M., Varona, E., López, F., Montero, M., Gómez, M.T., Bartibas, P., Sanz, R., Montes, T., Salinero, M.Á., Herrero, M., Igea, M., Calvo, C., Pérez-Pellón, C., Maestre, M., Agora, M.A., Martín, M.G., Velázquez, D., Fernández, B., Castro, M., Ayuso, E., Masa, R., Antelo, C., García, S., Herrero, S., Delgado, A., Vilardell, L., Puig-Vives, M., Osca-Gelis, G., Buxo, M., Izquierdo, A., Carmona-Garcia, M.C., Romanos, R.R., Galindo, C.T., Bargalló, P.M., Sanchez, E.R., Saez, M., Roncero, J.M., Gallardo, D., Coll, R., Blanco, I., Ruano, L.M., Castaño, E.A., Rusiñol, J.M., Perez, R.J., Pujol, I.M., Tuero, G.C., de Barrio Lera, J.P., Carral, J.M., Pérez, C.A., Puente, M.E., Balbuena, S.P., Presa, J.M., Ramírez, J.A., Martínez, A.Á., de Francisco, T.G., Elosua, T.G., Teso, E.P., Fueyo, J.F., Guadarrama, O.A., Turienzo Frade Mdel, A., De la Hoz Riesco, M., Fernández, J.J., Fernández, V.S., Fernández, R.C., Santamaría, M.V., Simón, J.A., Ganso, A.M., Pacho, A.V., Alegre, S.V., Plaza, F.J., Cuenllas, B.Á., Franco, E.H., Martín, M.H., Ariño, M.T., Tascón, C.D., Palomo, J.A., Castañón López Mdel, C., Lorenzo, M.P., González, I.A., Rivero, F.G., Román, C.H., Fernández, E.Á., Bayón, T.R., Fernández, A.G., Municio, F., de Celis, M.G., Ingelmo, L.Á., Herrero, J.G., Carbajo, M.J., Esteras, T.R., Baz, B.V., Baticón, C.H., Baza, E.Á., Urdiales, A.U., Gil, J.I., López, M.A., Ule, E.C., Diez, C.B., Marín, A.I., Bernabeu, M.Á., de Abajo Olea, S., Rojo, C.V., Fernández, M.Á., González, F.G., Martínez, L.G., Del Huertotrancón Moratiel, M., Ramos, N.C., Fidalgo, S.P., Coque, P.R., González, Á.G., Díez, A.B.

Cluster detection has become an important part of the agenda of epidemiologists and public health authorities, the identification of high- and low-risk areas is fundamental in the definition of public health strategies and in the suggestion of potential risks factors. Currently, there are different cluster detection techniques available, the most popular being those using windows to scan the areas within the studied region. However, when these areas are heterogeneous in populations' sizes, scan window methods can lead to inaccurate conclusions. In order to perform cluster detection over heterogeneously populated areas, we developed a method not based on scanning windows but instead on standard mortality ratios (SMR) using irregular spatial aggregation (ISA). Its extension, i.e. irregular spatial aggregation with covariates (ISAC), includes covariates with residuals from Poisson regression. We compared the performance of the method with the flexible shaped spatial scan statistic (FlexScan) using mortality data for stomach and bladder cancer for 8,098 Spanish towns. The results show a collection of clusters for stomach and bladder cancer similar to that detected by ISA and FlexScan. However, in general, clusters detected by FlexScan were bigger and include towns with SMR, which were not statistically significant. For bladder cancer, clusters detected by ISAC differed from those detected by ISA and FlexScan in shape and location. The ISA and ISAC methods could be an alternative to the traditional scan window methods for cluster detection over aggregated data when the areas under study are heterogeneous in terms of population. The simplicity and flexibility of the methods make them more attractive than methods based on more complicated algorithms. This study was funded by Spain’s Health Research Fund (Fondo de Investigación Sanitaria - FIS) Grant PI11/00871. Sí

Background A total of 2,514,346 metric tons (Mt) of asbestos were imported into Spain from 1906 until the ban on asbestos in 2002. Our objective was to study pleural cancer mortality trends as an indicator of mesothelioma mortality and update mortality predictions for the periods 2011–2015 and 2016–2020 in Spain., Methods Log-linear Poisson models were fitted to study the effect of age, period of death and birth cohort (APC) on mortality trends. Change points in cohort- and period-effect curvatures were assessed using segmented regression. Fractional power-link APC models were used to predict mortality until 2020. In addition, an alternative model based on national asbestos consumption figures was also used to perform long-term predictions., Results Pleural cancer deaths increased across the study period, rising from 491 in 1976–1980 to 1,249 in 2006–2010. Predictions for the five-year period 2016–2020 indicated a total of 1,319 pleural cancer deaths (264 deaths/year). Forecasts up to 2020 indicated that this increase would continue, though the age-adjusted rates showed a levelling-off in male mortality from 2001 to 2005, corresponding to the lower risk in post-1960 generations. Among women, rates were lower and the mortality trend was also different, indicating that occupational exposure was possibly the single factor having most influence on pleural cancer mortality., Conclusion The cancer mortality-related consequences of human exposure to asbestos are set to persist and remain in evidence until the last surviving members of the exposed cohorts have disappeared. It can thus be assumed that occupationally-related deaths due to pleural mesothelioma will continue to occur in Spain until at least 2040., The study was partially supported by a research grant from the Spanish Health Research Fund (FIS PI11/00871) and the HAR2009-07543 project of the Ministry of Science and Innovation. The Department of Labour of the Government of Catalonia provided the asbestos consumption data.

Spatial aggregation of different industrial facilities leads to simultaneous release of pollutant emissions. Our objective is to study cancer mortality risk associated with residence in the vicinity of pollutant factories. We used data on industries for year 2007 (3458 facilities). For the 8,098 Spanish towns, we defined a factor with 4 levels based on the number of factories in a radius of 2.5 km from the centroid of each town (industrial factor). We also used data of land cover use to approximate the percentage of municipal land used for industrial activities in each Spanish town (land-used variable). For both variables we fitted Poisson models with random terms to account for spatial variation. We estimated risk trends related with increasing number of factories or percentage of land used for industrial activities. We studied 33 cancer causes. For the industrial factor, 11 causes showed trend associated with increasing factor level. For the land use variable, 8 causes showed statistically significant risks. Almost all tumours related to the digestive system and the respiratory system showed increased risks. Thus mortality by these tumours could be associated to residence in towns nearby industrial areas with positive trend linked to increasing levels of industrial activity.

Background: The cause of coronary disease inframortality in Spain is unknown. The aim of this study is to identify Spanish towns with very low ischemic heart disease mortality, describe their health and social characteristics, and analyze the relationship with a series of contextual factors. Methods: We obtained the number of deaths registered for each of 8,122 Spanish towns in the periods 1989-1998 and 1999-2003. Expected deaths, standardized mortality ratio (SMR), smoothed Relative Risk (RR), and Posterior Probability (PP) of RR > 1 were calculated using Bayesian hierarchical models. Inframortality was defined as any town that displayed an RR below the 10th percentile, an SMR of under 1 for both sexes, and a PP of RR > 1 less than or equal to 0.002 for male and 0.005 for female mortality, during the two periods covered. All the remaining towns, except for those with high mortality classified as “tourist towns”, were selected as controls. The association among socioeconomic, health, dietary, lifestyle and vascular risk factors was analyzed using sequential mixed logistic regression models, with province as the random-effects variable. Results: We identified 32 towns in which ischemic heart disease mortality was half the national rate and four times lower than the European Union rate, situated in lightly populated provinces spread across the northern half of Spain, and revealed a surprising pattern of geographic aggegation for 23 of the 32 towns. Variables related with inframortality were: a less aged population (OR 0.93, 95% CI 0.89-0.99); a contextual dietary pattern marked by a high fish content (OR 2.13, 95% CI 1.38-3.28) and wine consumption (OR 1.50, 95% CI 1.08-2.07); and a low prevalence of obesity (OR 0.47, 95% CI 0.22-1.01); and, in the case of towns of over 1000 inhabitants, a higher physician-population ratio (OR 3.80, 95% CI 1.17-12.3). Conclusions: Results indicate that dietary and health care factors have an influence on inframortality. The geographical aggregation suggests that other factors with a spatial pattern, e.g., genetic or environmental might also be implicated. These results will have to be confirmed by studies in situ, with objective measurements at an individual level, This study was funded by research study grant no. PI06/0656 from Spain’s Health Research Fund (Fondo de Investigación Sanitaria)

BACKGROUND: Installations that burn fossil fuels to generate power may represent a health problem due to the toxic substances which they release into the environment. OBJECTIVES: To investigate whether there might be excess mortality due to tumors of lung, larynx and bladder in the population residing near Spanish combustion installations included in the European Pollutant Emission Register. METHODS: Ecologic study designed to model sex-specific standardized mortality ratios for the above three tumors in Spanish towns, over the period 1994-2003. Population exposure to pollution was estimated on the basis of distance from town of residence to pollution source. Using mixed Poisson regression models, we analyzed: risk of dying from cancer in a 5-kilometer zone around installations that commenced operations before 1990; effect of type of fuel used; and risk gradient within a 50-kilometer radius of such installations. RESULTS: Excess mortality (relative risk, 95% confidence interval) was detected in the vicinity of pre-1990 installations for lung cancer (1.066, 1.041-1.091 in the overall population; 1.084, 1.057-1.111 in men), and laryngeal cancer among men (1.067, 0.992-1.148). Lung cancer displayed excess mortality for all types of fuel used, whereas in laryngeal and bladder cancer, the excess was associated with coal-fired industries. There was a risk gradient effect in the proximity of a number of installations. CONCLUSIONS: Our results could support the hypothesis of an association between risk of lung, laryngeal and bladder cancer mortality and proximity to Spanish combustion installations. This study was funded by Spain's Health Research Fund (Fondo de Investigación Sanitaria - FIS 040041) and formed part of the MEDEA project (Mortalidad en áreas pequeñas Españolas y Desigualdades socio-Económicas y Ambientales — Mortality in small Spanish areas and socio-economic and environmental inequalities).

BACKGROUND: The European Pollutant Emission Register in Spain (EPER-Spain) is a public inventory of pollutant industries created by decision of the European Union. The location of these industries is geocoded and the first published data correspond to 2001. Publication of these data will allow for quantification of the effect of proximity to one or more such plant on cancer and all-cause mortality observed in nearby towns. However, as errors have been detected in the geocoding of many of the pollutant foci shown in the EPER, it was decided that a validation study should be conducted into the accuracy of these co-ordinates. EPER-Spain geographic co-ordinates were drawn from the European Environment Agency (EEA) server and the Spanish Ministry of the Environment (MOE). The Farm Plot Geographic Information System (Sistema de Información Geográfica de Parcelas Agrícolas) (SIGPAC) enables orthophotos (digitalized aerial images) of any territorial point across Spain to be obtained. Through a search of co-ordinates in the SIGPAC, all the industrial foci (except farms) were located. The quality criteria used to ascertain possible errors in industrial location were high, medium and low quality, where industries were situated at a distance of less than 500 metres, more than 500 metres but less than 1 kilometre, and more than 1 kilometre from their real locations, respectively. RESULTS: Insofar as initial registry quality was concerned, 84% of industrial complexes were inaccurately positioned (low quality) according to EEA data versus 60% for Spanish MOE data. The distribution of the distances between the original and corrected co-ordinates for each of the industries on the registry revealed that the median error was 2.55 kilometres for Spain overall (according to EEA data). The Autonomous Regions that displayed most errors in industrial geocoding were Murcia, Canary Islands, Andalusia and Madrid. Correct co-ordinates were successfully allocated to 100% of EPER-Spain industries. CONCLUSION: Knowing the exact location of pollutant foci is vital to obtain reliable and valid conclusions in any study where distance to the focus is a decisive factor, as in the case of the consequences of industrial pollution on the health of neighbouring populations. This study was funded by grant FIS 040041 from the Health Research Fund (Fondo de Investigación Sanitaria) Sí

BACKGROUND: Since the second half of the 1990s, kidney cancer mortality has tended to stabilize and decline in many European countries, due to the decrease in the prevalence of smokers. Nevertheless, incidence of kidney cancer is rising across the sexes in some of these countries, a trend which may possibly reflect the fact that improvements in diagnostic techniques are being outweighed by the increased prevalence of some of this tumor's risk factors. This study sought to: examine the geographic pattern of kidney cancer mortality in Spain; suggest possible hypotheses that would help explain these patterns; and enhance existing knowledge about the large proportion of kidney tumors whose cause remains unknown. METHODS: Smoothed municipal relative risks (RRs) for kidney cancer mortality were calculated in men and women, using the conditional autoregressive model proposed by Besag, York and Molliè. Maps were plotted depicting smoothed relative risk estimates, and the distribution of the posterior probability of RR>1 by sex. RESULTS: Municipal maps displayed a marked geographic pattern, with excess mortality in both sexes, mainly in towns along the Bay of Biscay, including areas of Asturias, the Basque Country and, to a lesser extent, Cantabria. Among women, the geographic pattern was strikingly singular, not in evidence for any other tumors, and marked by excess risk in towns situated in the Salamanca area and Extremaduran Autonomous Region. This difference would lead one to postulate the existence of different exposures of environmental origin in the various regions. CONCLUSION: The reasons for this pattern of distribution are not clear, and it would thus be of interest if the effect of industrial emissions on this disease could be studied. The excess mortality observed among women in towns situated in areas with a high degree of natural radiation could reflect the influence of exposures which derive from the geologic composition of the terrain and then become manifest through the agency of drinking water. This study was financed by Grant No. EPY-1176/02 from the Carlos III Institute of Health (ISCIII) and the Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP). Sí

Background Childhood cancer is the main cause of disease-related death in children in Spain. Although little is known about the etiology, environmental factors are potential explanations for a fraction of the cases. Previous studies have shown pesticides to be associated with childhood cancer. The difficulty of collecting personal environmental exposure data is an important limitation; this lack of information about pesticides motivates the development of new methods to subrogate this exposure. We developed a crop exposure index based on geographic information to study the relationship between exposure to different types of crops and risk of childhood tumors. Methods We conducted a population-based case–control study of childhood cancer covering 3350 cases and 20,365 controls in two Spanish regions. We used CORINE Land Cover to obtain data about agricultural land use. We created a 1 km buffer around every child and calculated the percentage of crop surface within the buffer (Global Crop Index) for total crops and for individual types of crops. We fitted mixed multiple unconditional logistic regression models by diagnostic group. Results We found excess of risk among children living in the proximity of crops. For total crops our results showed excesses of risk for almost all diagnostic groups and increasing risk with increasing crop index value. Analyses by region and individual type of crop also showed excess of risk. Conclusion The results suggest that living in the proximity of cultivated land could be a risk factor for several types of cancer in children. This study was funded by Spain’s Health Research Fund (Fondo de Investigación Sanitaria—FIS 12/01416) and Scientific Foundation of the Spanish Association Against Cancer (Fundación Científica de la Asociación Española Contra el Cáncer (AECC)—EVP-1178/14). Sí

BACKGROUND: New disease mapping techniques widely used in small-area studies enable disease distribution patterns to be identified and have become extremely popular in the field of public health. This paper reports on trends in the geographical mortality patterns of the most frequent cancers in Spain, over a period of 20 years. METHODS: We studied the municipal spatial pattern of stomach, colorectal, lung, breast, prostate and urinary bladder cancer mortality in Spain across four quinquennia, spanning the period 1989-2008. Case data were broken down by town (8073 municipalities), period and sex. Expected cases for each town were calculated using reference rates for each five-year period. For map plotting purposes, smoothed municipal relative risks were calculated using the conditional autoregressive model proposed by Besag, York and Mollié, with independent data for each quinquennium. We evaluated the presence of spatial patterns in maps on the basis of models, calculating the variance in relative risk corresponding to the structured spatial component and the unstructured component, as well as the proportion of variance explained by the structured spatial component. RESULTS: The mortality patterns observed for stomach, colorectal and lung cancer were maintained over the 20 years covered by the study. Prostate cancer and the tumours studied in women showed no defined spatial pattern, with the single exception of stomach cancer. The trend in spatial fractional variance indicated the possibility of a change in the spatial pattern in breast, bladder and colorectal cancer in women during the last five-year period. The paper goes on to discuss ways in which spatio-temporal data are depicted in the case of cancer, and review the risk factors that may possibly influence the respective tumours' spatial patterns. CONCLUSION: In men, the marked geographical patterns of stomach, colorectal, lung and bladder cancer remained stable over time. Breast, colorectal and bladder cancer in women show signs of the possible appearance of a spatial pattern in Spain and should therefore be monitored. The study was partially supported by a research grant from the Spanish Health Research Fund (FIS PI11/00871). Mortality data were supplied by the Spanish National Statistics Institute in accordance with a specific confidentiality protocol. Thanks to Olivier Nuñez for his comments about interpretation of some aspects of models results. Sí

BACKGROUND: Worldwide, Cervical Cancer (CC) is the fourth most common type of cancer and cause of death in women. It is a significant public health problem, especially in low and middle-income/Gross Domestic Product (GDP) countries. In the past decade, several studies of CC have been published, that identify the main modifiable and non-modifiable CC risk factors for Mexican women. However, there are no studies that attempt to explain the residual spatial variation in CC incidence In Mexico, i.e. spatial variation that cannot be ascribed to known, spatially varying risk factors. METHODS: This paper uses a spatial statistical methodology that takes into account spatial variation in socio-economic factors and accessibility to health services, whilst allowing for residual, unexplained spatial variation in risk. To describe residual spatial variations in CC risk, we used generalised linear mixed models (GLMM) with both spatially structured and unstructured random effects, using a Bayesian approach to inference. RESULTS: The highest risk is concentrated in the southeast, where the Matlapa and Aquismón municipalities register excessive risk, with posterior probabilities greater than 0.8. The lack of coverage of Cervical Cancer-Screening Programme (CCSP) (RR 1.17, 95 % CI 1.12-1.22), Marginalisation Index (RR 1.05, 95 % CI 1.03-1.08), and lack of accessibility to health services (RR 1.01, 95 % CI 1.00-1.03) were significant covariates. CONCLUSIONS: There are substantial differences between municipalities, with high-risk areas mainly in low-resource areas lacking accessibility to health services for CC. Our results clearly indicate the presence of spatial patterns, and the relevance of the spatial analysis for public health intervention. Ignoring the spatial variability means to continue a public policy that does not tackle deficiencies in its national CCSP and to keep disadvantaging and disempowering Mexican women in regard to their health care. Sí