Search

BackgroundQ fever is a bacterial zoonosis caused by Coxiella burnetii. Spain has the highest number of notified human cases in Europe. Small ruminants are a key reservoir for the pathogen, transmission from animals to humans is usually airborne.AimWe aimed at exploring temporal and spatial epidemiological patterns of sporadic and outbreak cases of Q fever in four Spanish regions with the highest number of notified cases.MethodsWe extracted data on Q fever cases in the Canary Islands, Basque Country, La Rioja and Navarre between 2016 and 2022 from the Spanish National Epidemiological Surveillance Network. We calculated standardised incidence ratios (SIR), spatial relative risks (sRR) and posterior probabilities (PP) utilising Besag-York-Mollié models.ResultsThere were 1,059 notifications, with a predominance of males aged 30-60 years. In Basque Country, La Rioja and Navarre area, 11 outbreaks were reported, while no in the Canary Islands. A seasonal increase in incidence rates was observed between March and June. In the Canary Islands, elevated sRR was seen in La Palma, Gran Canaria, Lanzarote and Fuerteventura. In Basque Country, La Rioja and Navarre area, the highest sRR was identified in the south of Biscay province.ConclusionGoats were the main source for humans in outbreaks reported in the literature. Seasonal increase may be related to the parturition season of small ruminants and specific environmental conditions. Local variations in sRR within these regions likely result from diverse environmental factors. Future One Health-oriented studies are essential to deepen our understanding of Q fever epidemiology.

Malaria remains one of the most important infectious diseases globally due to its high incidence and mortality rates. The influx of infected cases from endemic to non-endemic malaria regions like Europe has resulted in a public health concern over sporadic local outbreaks. This is facilitated by the continued presence of competent Anopheles vectors in non-endemic countries.We modelled the potential distribution of the main malaria vector across Spain using the ensemble of eight modelling techniques based on environmental parameters and the Anopheles maculipennis s.l. presence/absence data collected from 2000 to 2020. We then combined this map with the number of imported malaria cases in each municipality to detect the geographic hot spots with a higher risk of local malaria transmission.The malaria vector occurred preferentially in irrigated lands characterized by warm climate conditions and moderate annual precipitation. Some areas surrounding irrigated lands in northern Spain (e.g. Zaragoza, Logroño), mainland areas (e.g. Madrid, Toledo) and in the South (e.g. Huelva), presented a significant likelihood of A. maculipennis s.l. occurrence, with a large overlap with the presence of imported cases of malaria.While the risk of malaria re-emergence in Spain is low, it is not evenly distributed throughout the country. The four recorded local cases of mosquito-borne transmission occurred in areas with a high overlap of imported cases and mosquito presence. Integrating mosquito distribution with human incidence cases provides an effective tool for the quantification of large-scale geographic variation in transmission risk and pinpointing priority areas for targeted surveillance and prevention.

Background: Understanding the patterns of disease importation through international travel is paramount for effective public health interventions and global disease surveillance. While global airline network data have been used to assist in outbreak prevention and effective preparedness, accurately estimating how these imported cases disseminate locally in receiving countries remains a challenge., Objective: This study aimed to describe and understand the regional distribution of imported cases of dengue and malaria upon arrival in Spain via air travel., Methods: We have proposed a method to describe the regional distribution of imported cases of dengue and malaria based on the computation of the "travelers' index" from readily available socioeconomic data. We combined indicators representing the main drivers for international travel, including tourism, economy, and visits to friends and relatives, to measure the relative appeal of each region in the importing country for travelers. We validated the resulting estimates by comparing them with the reported cases of malaria and dengue in Spain from 2015 to 2019. We also assessed which motivation provided more accurate estimates for imported cases of both diseases., Results: The estimates provided by the best fitted model showed high correlation with notified cases of malaria (0.94) and dengue (0.87), with economic motivation being the most relevant for imported cases of malaria and visits to friends and relatives being the most relevant for imported cases of dengue., Conclusions: Factual descriptions of the local movement of international travelers may substantially enhance the design of cost-effective prevention policies and control strategies, and essentially contribute to decision-support systems. Our approach contributes in this direction by providing a reliable estimate of the number of imported cases of nonendemic diseases, which could be generalized to other applications. Realistic risk assessments will be obtained by combining this regional predictor with the observed local distribution of vectors., (©David García-García, Beatriz Fernández-Martínez, Frederic Bartumeus, Diana Gómez-Barroso. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 27.05.2024.)

Tuberculosis (TB) remains a global leading cause of death, necessitating an investigation into its unequal distribution. Sun exposure, linked to vitamin D (VD) synthesis, has been proposed as a protective factor. This study aimed to analyse TB rates in Spain over time and space and explore their relationship with sunlight exposure. An ecological study examined the associations between rainfall, sunshine hours, and TB incidence in Spain. Data from the National Epidemiological Surveillance Network (RENAVE in Spanish) and the Spanish Meteorological Agency (AEMET in Spanish) from 2012 to 2020 were utilized. Correlation and spatial regression analyses were conducted. Between 2012 and 2020, 43,419 non-imported TB cases were reported. A geographic pattern (north-south) and distinct seasonality (spring peaks and autumn troughs) were observed. Sunshine hours and rainfall displayed a strong negative correlation. Spatial regression and seasonal models identified a negative correlation between TB incidence and sunshine hours, with a four-month lag. A clear spatiotemporal association between TB incidence and sunshine hours emerged in Spain from 2012 to 2020. VD levels likely mediate this relationship, being influenced by sunlight exposure and TB development. Further research is warranted to elucidate the causal pathway and inform public health strategies for improved TB control.

In Spain, the largest human West Nile virus (WNV) outbreak among humans was reported in 2020, constituting the second most important outbreak in Europe that season. Extremadura (southwestern Spain) was one of the affected areas, reporting six human cases. The first autochthonous human case in Spain was reported in Extremadura in 2004, and no other human cases were reported until 2020. In this work, we describe the first WNV human outbreak registered in Extremadura, focusing on the most important clinical aspects, diagnostic results, and control actions which followed. In 2020, from September to October, human WNV infections were diagnosed using a combination of molecular and serological methods (an in-house specific qRT-PCR and a commercial ELISA for anti-WNV IgM and IgG antibodies) and by analysing serum, urine, and/or cerebrospinal fluid samples. Serological positive serum samples were further tested using commercial kits against related flaviviruses Usutu and Tick-borne encephalitis in order to analyse serological reactivity and to confirm the results by neutralisation assays. In total, six cases of WNV infection (five with neuroinvasive disease and one with fever) were identified. Clinical presentation and laboratory findings are described. No viral RNA was detected in any of the analysed samples, but serological cross-reactivity was detected against the other tested flaviviruses. Molecular and serological methods for WNV detection in various samples as well as differential diagnosis are recommended. The largest number of human cases of WNV infection ever registered in Extremadura, Spain, occurred in 2020 in areas where circulation of WNV and other flaviviruses has been previously reported in humans and animals. Therefore, it is necessary to enhance surveillance not only for the early detection and implementation of response measures for WNV but also for other emerging flaviviruses that could be endemic in this area., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Macias, Martín, Pérez-Olmeda, Fernández-Martínez, Gómez-Barroso, Fernández, Ramos, Herrero, Rodríguez, Delgado, Sánchez-Seco, Galán, Corbacho, Jimenez, Montero-Peña, Valle and Vázquez.)

We analysed the transmission of the human mpox virus in Spain by estimating the effective reproduction number of the disease from official surveillance data. Our computations show that this decreased steadily after an initial burst phase, dropping below 1 on July 12, and thus the outbreak was expected to reduce in the following weeks. Differences in trends were found across geographical regions of the country and across MSM and heterosexual populations.

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.

The aim of our study was to describe the results of the epidemiological surveillance of hepatitis A infections in Spain in the context of the 2016/2017 European outbreak, particularly of hepatitis A outbreaks reported in the MSM population, incorporating the results of a spatio-temporal analysis of cases. Hepatitis A cases and outbreaks reported in 2016-2017 to the National Epidemiological Surveillance Network were reviewed: outbreaks in which some of the cases belonged to the MSM group were described, and clusters of hepatitis A cases in men and women were analysed using a space-time scan statistic. Twenty-six outbreaks were identified, with a median size of two cases per outbreak, with most of the outbreak-related cases belonging to the 15-44 years-old group. Nearly 85% occurred in a household setting, and in all outbreaks, the mode of transmission was direct person-to-person contact. Regarding space-time analysis, twenty statistically significant clusters were identified in the male population and eight in the female population; clusters in men presented a higher number of observed cases and affected municipalities, as well as a higher percentage of municipalities classified as large urban areas. The elevated number of cases detected in clusters of men indicates that the number of MSM-related outbreaks may be higher than reported, showing that spatio-temporal analysis is a complementary, useful tool which may improve the detection of outbreaks in settings where epidemiological investigation may be more challenging.

Background: To analyse differences in confirmed cases, hospitalisations and deaths due to COVID-19 related to census section socioeconomic variables.  METHODS: Ecological study in the 12 largest municipalities in Andalusia (Spain) during the first three epidemic waves of the COVID-19 (02/26/20-03/31/21), covering 2,246 census sections (unit of analysis) and 3,027,000 inhabitants. Incidence was calculated, standardised by age and sex, for infection, hospitalisation and deaths based on average gross income per household (AGI) for the census tracts in each urban area. Association studied using a Poisson Bayesian regression model with random effects for spatial smoothing., Results: There were 140,743 cases of COVID-19, of which 12,585 were hospitalised and 2,255 died. 95.2% of cases were attributed to the second and third waves, which were jointly analysed. We observed a protective effect of income for infection in 3/12 cities. Almeria had the largest protective effect (smoothed relative risk (SRR) = 0.84 (0.75-0.94 CI 95%). This relationship reappeared with greater magnitude in 10/12 cities for hospitalisation, lowest risk in Algeciras SRR = 0.41 (0.29-0.56). The pattern was repeated for deaths in all urban areas and reached statistical significance in 8 cities. Lowest risk in Dos Hermanas SRR = 0.35 (0.15-0.81)., Conclusions: Income inequalities by geographical area were found in the incidence of COVID-19. The strengths of the association increased when analysing the severe outcomes of hospitalisations and, above all, deaths., (© 2022. The Author(s).)

BackgroundAfter 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.AimTo analyse which implemented NPIs significantly impacted effective reproduction number (R t ) in seven Spanish provinces during 30 August 2020-31 January 2021.MethodsWe 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 R t 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 R t of the global SI (stringency) and the individual SIs (separate effect of NPIs).ResultsThe global SI had a significant lowering effect on the R t (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 R t as a response variable.ConclusionWhile 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.

Background: Blue spaces have been a key part of human evolution, providing resources and helping economies develop. To date, no studies have been carried out to explore how they may be linked to paediatric oncological diseases., Objectives: To explore the possible relationship of residential proximity to natural and urban blue spaces on childhood leukaemia., Methods: A population-based case-control study was conducted in four regions of Spain across the period 2000-2018. A total of 936 incident cases and 5616 controls were included, individually matched by sex, year of birth and place of residence. An exposure proxy with four distances (250 m, 500 m, 750 m, and 1 km) to blue spaces was built using the geographical coordinates of the participants' home residences. Odds ratios (ORs) and 95% confidence intervals (95%CIs) for blue-space exposure were calculated for overall childhood leukaemia, and the acute lymphoblastic (ALL) and acute myeloblastic leukaemia (AML) subtypes, with adjustment for socio-demographic and environmental covariates., Results: A decrease in overall childhood leukaemia and ALL-subtype incidence was found as we came nearer to children's places of residence, showing, for the study as a whole, a reduced incidence at 250 m (odds ratio (OR) = 0.77; 95%CI = 0.60-0.97), 500 m (OR = 0.78; 95%CI = 0.65-0.93), 750 m (OR = 0.80; 95%CI = 0.69-0.93), and 1000 m (OR = 0.84; 95%CI = 0.72-0.97). AML model results showed an increasing incidence at closest to subjects' homes (OR at 250m = 1.06; 95%CI=0.63-1.71)., Conclusions: Our results suggest a possible association between lower childhood leukaemia incidence and blue-space proximity. This study is a first approach to blue spaces' possible effects on childhood leukaemia incidence; consequently, it is necessary to continue studying these spaces-while taking into account more individualised data and other possible environmental risk factors.

Introduction: Scabies is a neglected disease stablished worldwide with a fairy well determined incidence. In high-income countries, it often causes outbreaks affecting the residents and staff of institutions and long-term facilities, usually hard to detect and control due to the difficult diagnosis and notification delay. This study aim at characterizing the affected population, geographical distribution, and evolution of scabies in Spain from 1997-2019 as well as to describe the main environments of transmission using different data sources., Methods: We carried out a nationwide retrospective study using four databases, which record data from different perspectives: hospital admissions, patients attended at primary healthcare services, outbreaks, and occupational diseases. We described the main characteristics from each database and calculated annual incidences in order to evaluate temporal and geographical patterns. We also analyzed outbreaks and occupational settings to characterize the main transmission foci and applied Joinpoint regression models to detect trend changes., Results: The elderly was the most frequent collective among the hospital admitted patients and notified cases in outbreaks, while children and young adults were the most affected according to primary care databases. The majority of the outbreaks occurred in homes and nursing homes; however, the facilities with more cases per outbreak were military barracks, healthcare settings and nursing homes. Most occupational cases occurred also in healthcare and social services settings, being healthcare workers the most common affected professional group. We detected a decreasing trend in scabies admissions from 1997 to 2014 (annual percentage change -APC- = -11.2%) and an increasing trend from 2014 to 2017 (APC = 23.6%). Wide geographical differences were observed depending on the database explored., Discussion: An increasing trend in scabies admissions was observed in Spain since 2014, probably due to cutbacks in social services and healthcare in addition to worsen of living conditions as a result of the 2008 economic crisis, among other reasons. The main transmission foci were healthcare and social settings. Measures including enhancing epidemic studies and national registries, reinforcing clinical diagnosis and early detection of cases, hygiene improvements and training of the staff and wide implementation of scabies treatment (considering mass drug administration in institutions outbreaks) should be considered to reduce the impact of scabies among most vulnerable groups in Spain., Competing Interests: The authors have declared that no competing interests exist.

Background: On June 21st de-escalation measures and state-of-alarm ended in Spain after the COVID-19 first wave. New surveillance and control strategy was set up to detect emerging outbreaks., Aim: To detect and describe the evolution of COVID-19 clusters and cases during the 2020 summer in Spain., Methods: A near-real time surveillance system to detect active clusters of COVID-19 was developed based on Kulldorf's prospective space-time scan statistic (STSS) to detect daily emerging active clusters., Results: Analyses were performed daily during the summer 2020 (June 21st - August 31st) in Spain, showing an increase of active clusters and municipalities affected. Spread happened in the study period from a few, low-cases, regional-located clusters in June to a nationwide distribution of bigger clusters encompassing a higher average number of municipalities and total cases by end-August., Conclusion: STSS-based surveillance of COVID-19 can be of utility in a low-incidence scenario to help tackle emerging outbreaks that could potentially drive a widespread transmission. If that happens, spatial trends and disease distribution can be followed with this method. Finally, cluster aggregation in space and time, as observed in our results, could suggest the occurrence of community transmission.

Mosquito borne diseases are a group of infections that affect humans. Emerging or reemerging diseases are those that (re)occur in regions, groups or hosts that were previously free from these diseases: dengue virus; chikungunya virus; Zika virus; West Nile fever and malaria. In Europe, these infections are mostly imported; however, due to the presence of competent mosquitoes and the number of trips both to and from endemic areas, these pathogens are potentially emergent or re-emergent. Present and future climatic conditions, as well as meteorological, environmental and demographic aspects are risk factors for the distribution of different vectors and/or diseases. This review aimed to identify and analyze the existing literature on the transmission of mosquito borne diseases and those factors potentially affecting their transmission risk of them in six southern European countries with similar environmental conditions: Croatia, France, Greece, Italy, Portugal and Spain. In addition, we would identify those factors potentially affecting the (re)introduction or spread of mosquito vectors. This task has been undertaken with a focus on the environmental and climatic factors, including the effects of climate change. We undertook a systematic review of the vectors, diseases and their associations with climactic and environmental factors in European countries of the Mediterranean region. We followed the PRISMA guidelines and used explicit and systematic methods to identify, select and critically evaluate the studies which were relevant to the topic. We identified 1302 articles in the first search of the databases. Of those, 160 were selected for full-text review. The final data set included 61 articles published between 2000 and 2017.39.3% of the papers were related with dengue, chikungunya and Zika virus or their vectors. Temperature, precipitation and population density were key factors among others. 32.8% studied West Nile virus and its vectors, being temperature, precipitation and NDVI the most frequently used variables. Malaria have been studied in 23% of the articles, with temperature, precipitation and presence of water indexes as the most used variables. The number of publications focused on mosquito borne diseases is increasing in recent years, reflecting the increased interest in that diseases in southern European countries. Climatic and environmental variables are key factors on mosquitoes' distribution and to show the risk of emergence and/or spread of emergent diseases and to study the spatial changes in that distributions., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

During the first months of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) epidemic in 2020, Spain implemented an initial lockdown period on 15 March followed by a strengthened lockdown period on 30 March when only essential workers continued to commute to work. However, little is known about the epidemic dynamics in different age groups during these periods.We used the daily number of coronavirus 2019 cases (by date of symptom onset) reported to the National Epidemiological Surveillance Network among individuals aged 15-19 years through 65-69 years. For each age group g, we computed the proportion PrE(g) of individuals in age group g among all reported cases aged 15-69 years during the pre-lockdown period (1-10 March 2020) and the corresponding proportion PrL(g) during two lockdown periods (initial: 25 March-3 April; strengthened: 8-17 April 2020). For each lockdown period, we computed the proportion ratios PR(g) = PrL(g)/PrE(g). For each pair of age groups g1, g2, PR(g1)>PR(g2) implies a relative increase in the incidence of detected SARS-CoV-2 infection in the age group g1 compared with g2 for the lockdown period vs. the pre-lockdown period.For the initial lockdown period, the highest PR values were in age groups 50-54 years (PR = 1.21; 95% CI: 1.12,1.30) and 55-59 years (PR = 1.19; 1.11,1.27). For the second lockdown period, the highest PR values were in age groups 15-19 years (PR = 1.26; 0.95,1.68) and 50-54 years (PR = 1.20; 1.09,1.31).Our results suggest that different outbreak control measures led to different changes in the relative incidence by age group. During the initial lockdown period, when non-essential work was allowed, individuals aged 40-64 years, particularly those aged 50-59 years, had a higher relative incidence compared with the pre-lockdown period. Younger adults/older adolescents had an increased relative incidence during the later, strengthened lockdown. The role of different age groups during the epidemic should be considered when implementing future mitigation efforts.

Background: The aim of this study is to explore whether transmission of M. leprae has ceased in Spain, based upon the patterns and trends of notified cases., Methodology: Data on new cases reported to the National Leprosy Registry between the years 2003-2018 were extracted. In absence of detailed travel history, cases were considered "autochthonous" or "imported" based on whether they were born within or outside of Spain. These data were analyzed by age, sex, clinical type, country of origin, and location of residence at time of notification., Principal Findings: Data were available on 61 autochthonous and 199 imported cases since 2003. There were clear declines in incidence in both groups, and more imported than autochthonous cases every year since 2006. Autochthonous cases were more frequently multibacillary and had older age at diagnosis compared to imported cases. All the autochthonous cases had been born before 1985 and were more than 25 years old at diagnosis. Male-to-female ratio increased with time for autochthonous cases (except for the last time period). The imported cases originated from 25 countries, half of them from Brasil and Paraguay. Autochthonous cases were mainly distributed in the traditionally endemic regions, especially Andalucía and the eastern Mediterranean coast., Conclusions: Autochthonous and imported cases have different epidemiologic patterns in Spain. There was a clear decline in incidence rates of autochthonous disease, and patterns consistent with those reported from other regions where transmission has ceased. Autochthonous transmission of M. leprae is likely to have now effectively stopped in Spain., Competing Interests: The authors have declared that no competing interests exist.

Changes in environmental conditions, whether related or not to human activities, are continuously modifying the geographic distribution of vectors, which in turn affects the dynamics and distribution of vector-borne infectious diseases. Determining the main ecological drivers of vector distribution and how predicted changes in these drivers may alter their future distributions is therefore of major importance. However, the drivers of vector populations are largely specific to each vector species and region. Here, we identify the most important human-activity-related and bioclimatic predictors affecting the current distribution and habitat suitability of the mosquito Culex pipiens and potential future changes in its distribution in Spain. We determined the niche of occurrence (NOO) of the species, which considers only those areas lying within the range of suitable environmental conditions using presence data. Although almost ubiquitous, the distribution of Cx. pipiens is mostly explained by elevation and the degree of urbanization but also, to a lesser extent, by mean temperatures during the wettest season and temperature seasonality. The combination of these predictors highlights the existence of a heterogeneous pattern of habitat suitability, with most suitable areas located in the southern and northeastern coastal areas of Spain, and unsuitable areas located at higher altitude and in colder regions. Future climatic predictions indicate a net decrease in distribution of up to 29.55%, probably due to warming and greater temperature oscillations. Despite these predicted changes in vector distribution, their effects on the incidence of infectious diseases are, however, difficult to forecast since different processes such as local adaptation to temperature, vector-pathogen interactions, and human-derived changes in landscape may play important roles in shaping the future dynamics of pathogen transmission., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Mediterranean spotted fever (MSF) is a zoonotic disease caused by Rickettsia conorii and transmitted by Rhipicephalus sanguineus sensu lato. The aim of this study is to understand the epidemiology and trends regarding the disease in Spain, based on notifications to the Spanish National Epidemiology Surveillance Network (RENAVE) and the National Hospital Discharge Database (CMBD) between 2005 and 2015., Methods: We carried out a retrospective cross-sectional study of the cases and the outbreaks reported to the RENAVE and of those found in the CMBD between January 1 st , 2005 and December 31 st , 2015. We studied the characteristics of the cases and analyzed their spatio-temporal distribution., Results: 1603 cases notified to the RENAVE and 1789 cases registered in the CMBD were analyzed. The most affected group were men between 45 and 64. There were 8 MSF outbreaks during the study period. RENAVE registered lower rates until 2012, when it was decided that MSF in Spain would become a notifiable disease. Across the temporal series we saw that there was seasonality with an increase in cases in summer, and an overall upward trend according to the RENAVE data and descending according to the CMBD. The geographic distribution was heterogeneous throughout the territory, with maximum rates in La Rioja at 1.87 cases and 2.01 cases per 100,000 inhabitants according to the RENAVE and the CMBD, respectively., Conclusions: It is of great importance to continue monitoring the disease since it appears to be endemic throughout Spain. There is a need for a common strategy on monitoring and reporting, which would facilitate a more accurate picture on the MSF epidemiological scenario. Entomological information will be of added value., Competing Interests: Declaration of competing Interest None., (Copyright © 2019 Elsevier GmbH. All rights reserved.)

Background: Malaria was eliminated in Spain in 1964. Since then, more than 10,000 cases of malaria have been reported, mostly in travellers and migrants, making it the most frequently imported disease into this country. In order to improve knowledge on imported malaria cases characteristics, the two main malaria data sources were assessed: the national surveillance system and the hospital discharge database (CMBD)., Methods: Observational study using prospectively gathered surveillance data and CMBD records between 2002 and 2015. The average number of hospitalizations per year was calculated to assess temporal patterns. Socio-demographic, clinical and travel background information were analysed. Bivariate and multivariable statistical methods were employed to evaluate hospitalization risk, fatal outcome, continent of infection and chemoprophylaxis failure and their association with different factors., Results: A total of 9513 malaria hospital discharges and 7421 reported malaria cases were identified. The number of reported cases was below the number of hospitalizations during the whole study period, with a steady increase trend in both databases since 2008. Males aged 25-44 were the most represented in both data sources. Most frequent related co-diagnoses were anaemia (20.2%) and thrombocytopaenia (15.4%). The risks of fatal outcome increased with age and were associated with the parasite species (Plasmodium falciparum). The main place of infection was Africa (88.9%), particularly Equatorial Guinea (33.2%). Most reported cases were visiting friends and relatives (VFRs) and immigrants (70.2%). A significant increased likelihood of hospitalization was observed for children under 10 years (aOR:2.7; 95% CI 1.9-3.9), those infected by Plasmodium vivax (4.3; 95% CI 2.1-8.7) and travellers VFRs (1.4; 95% CI 1.1-1.7). Only 4% of cases reported a correct regime of chemoprophylaxis. Being male, over 15 years, VFRs, migrant and born in an endemic country were associated to increased risk of failure in preventive chemotherapy., Conclusions: The joint analysis of two data sources allowed for better characterization of imported malaria profile in Spain. Despite the availability of highly effective preventive measures, the preventable burden from malaria is high in Spain. Pre-travel advice and appropriately delivered preventive messages needs to be improved, particularly in migrants and VFRs.

Introduction and Objective: Zika virus disease is a challenge for public health due to its rapid spread and potential foetal complications. Although it is imported in Spain, there is a risk of autochthonous transmission due to Aedes albopictus presence. Zika disease and congenital cases have been under surveillance since 2016. The objective of this study is to explore the epidemiology of disease and pregnancies result., Material and Methods: A descriptive study was carried out into cases reported to the National Surveillance Network (RENAVE) during the 30/11/2015 to 31/12/2017 period. The case definition and the survey are included in the RENAVE protocol. The variables were: date; notifying region (Autonomous Community (AC)); pregnancy and its evolution; case classification; mode of transmission; country or region of infection; socio-demographical, clinical and microbiological data. A descriptive analysis of the cases and their distribution according to the other variables was carried out., Results: A total of 512 cases were reported by 17 ACs. 507 were non-congenital, of which 327 (64.5%) were women (52.5% of childbearing age). 403 cases (79.5%) corresponded to 2016 and 193 (38.1%) resided in regions with A. albopictus presence between May and October. 96.1% of imported cases were infected in America (51.7% while visiting relatives). Three cases (3.9%) of congenital Zika virus infection were detected among 77 pregnant women., Conclusions: The evolution of reported cases was in accordance with that of the epidemic in America. The largest group of travellers was young women who travelled to Latin America on family visits. Pregnancy monitoring resulted in the identification of Zika related foetal complications., (Copyright © 2019 Elsevier España, S.L.U. All rights reserved.)

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.

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 <50 m of the busiest motorways compared to controls (OR = 2.90; 95%CI = 1.30-6.49). The estimates for acute lymphoid leukaemia (ALL) were slightly higher (OR = 2.95; 95%CI = 1.22-7.14), while estimates for cases with the same address at birth and at diagnosis were lower (OR = 2.40; 95%CI = 0.70-8.30)., Conclusions: Our study agrees with the literature and furnishes some evidence that living near a busy motorway could be a risk factor for childhood leukaemia., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Few risk factors for childhood renal tumors are well established. While a small fraction of cases might be attributable to susceptibility genes and congenital anomalies, the role of environmental factors needs to be assessed., Objectives: To explore the possible association between residential proximity to environmental pollution sources (industrial and urban areas, and agricultural crops) and childhood renal cancer, taking into account industrial groups and toxic substances released., Methods: We conducted a population-based case-control study of childhood renal cancer in Spain, including 213 incident cases gathered from the Spanish Registry of Childhood Tumors (period 1996-2011), and 1278 controls individually matched by year of birth, sex, and region of residence. Distances were computed from the respective subject's residences to the 1271 industries, the 30 urban areas with ≥75,000 inhabitants, and the agricultural crops located in the study area. Using logistic regression, odds ratios (ORs) and 95% confidence intervals (95%CIs) for categories of distance to pollution sources were calculated, with adjustment for matching variables and socioeconomic confounders., Results: Excess risk (OR; 95%CI) of childhood renal tumors was observed for children living near (≤2.5km) industrial installations as a whole (1.97; 1.13-3.42) - particularly glass and mineral fibers (2.69; 1.19-6.08), galvanization (2.66; 1.14-6.22), hazardous waste (2.59; 1.25-5.37), ceramic (2.35; 1.06-5.21), surface treatment of metals (2.25; 1.24-4.08), organic chemical industry (2.22; 1.15-4.26), food and beverage sector (2.19; 1.18-4.07), urban and waste-water treatment plants (2.14; 1.07-4.30), and production and processing of metals (1.98; 1.03-3.82) -, and in the proximity of agricultural crops (3.16; 1.54-8.89 for children with percentage of crop surface ≥24.35% in a 1-km buffer around their residences)., Conclusions: Our study provides some epidemiological evidence that living near certain industrial areas and agricultural crops may be a risk factor for childhood renal cancer., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Few risk factors for the childhood leukemia are well established. While a small fraction of cases of childhood leukemia might be partially attributable to some diseases or ionizing radiation exposure, the role of industrial and urban pollution also needs to be assessed., Objectives: To ascertain the possible effect of residential proximity to both industrial and urban areas on childhood leukemia, taking into account industrial groups and toxic substances released., Methods: We conducted a population-based case-control study of childhood leukemia in Spain, covering 638 incident cases gathered from the Spanish Registry of Childhood Tumors and for those Autonomous Regions with 100% coverage (period 1990-2011), and 13,188 controls, individually matched by year of birth, sex, and autonomous region of residence. Distances were computed from the respective subject's residences to the 1068 industries and the 157 urban areas with ≥10,000 inhabitants, located in the study area. Using logistic regression, odds ratios (ORs) and 95% confidence intervals (95%CIs) for categories of distance to industrial and urban pollution sources were calculated, with adjustment for matching variables., Results: Excess risk of childhood leukemia was observed for children living near (≤2.5 km) industries (OR=1.31; 95%CI=1.03-1.67) - particularly glass and mineral fibers (OR=2.42; 95%CI=1.49-3.92), surface treatment using organic solvents (OR=1.87; 95%CI=1.24-2.83), galvanization (OR=1.86; 95%CI=1.07-3.21), production and processing of metals (OR=1.69; 95%CI=1.22-2.34), and surface treatment of metals (OR=1.62; 95%CI=1.22-2.15) - , and urban areas (OR=1.36; 95%CI=1.02-1.80)., Conclusions: Our study furnishes some evidence that living in the proximity of industrial and urban sites may be a risk factor for childhood leukemia., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Childhood cancer was the leading cause of death among children aged 1-14 years for 2012 in Spain. Leukemia has the highest incidence, followed by tumors of the central nervous system (CNS) and lymphomas (Hodgkin lymphoma, HL, and Non-Hodgkin's lymphoma, NHL). Spatial distribution of childhood cancer cases has been under concern with the aim of identifying potential risk factors., Objective: The two objectives are to study overall spatial clustering and cluster detection of cases of the three main childhood cancer causes, looking to increase etiological knowledge., Methods: We ran a case-control study. The cases were children aged 0 to 14 diagnosed with leukemia, lymphomas (HL and NHL) or CNS neoplasm in five Spanish regions for the period 1996-2011. As a control group, we used a sample from the Birth Registry matching every case by year of birth, autonomous region of residence and sex with six controls. We geocoded and validated the address of the cases and controls. For our two objectives we used two different methodologies. For the first, for overall spatial clustering detection, we used the differences of K functions from the spatial point patterns perspective proposed by Diggle and Chetwynd and the second, for cluster detection, we used the spatial scan statistic proposed by Kulldorff with a level for statistical significance of 0.05., Results: We had 1062 cases of leukemia, 714 cases of CNS, 92 of HL and 246 of NHL. Accordingly we had 6 times the number of controls, 6372 controls for leukemia, 4284 controls for CNS, 552 controls for HL and 1476 controls for NHL. We found variations in the estimated empirical D(s) for the different regions and cancers, including some overall spatial clustering for specific regions and distances. We did not find statistically significant clusters., Conclusions: The variations in the estimated empirical D(s) for the different regions and cancers could be partially explained by the differences in the spatial distribution of the population; however, according to the literature, we cannot discard environmental hazards or infections agents in the etiology of these cancers.

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.

A retrospective, space-time study of whooping cough cases reported to the Public Health Agency of Barcelona, Spain between the years 2000 and 2011 is presented. It is based on 633 individual whooping cough cases and the 2006 population census from the Spanish National Statistics Institute, stratified by age and sex at the census tract level. Cluster identification was attempted using space-time scan statistic assuming a Poisson distribution and restricting temporal extent to 7 days and spatial distance to 500 m. Statistical calculations were performed with Stata 11 and SatScan and mapping was performed with ArcGis 10.0. Only clusters showing statistical significance (P <0.05) were mapped. The most likely cluster identified included five census tracts located in three neighbourhoods in central Barcelona during the week from 17 to 23 August 2011. This cluster included five cases compared with the expected level of 0.0021 (relative risk = 2436, P <0.001). In addition, 11 secondary significant space-time clusters were detected with secondary clusters occurring at different times and localizations. Spatial statistics is felt to be useful by complementing epidemiological surveillance systems through visualizing excess in the number of cases in space and time and thus increase the possibility of identifying outbreaks not reported by the surveillance system.

Using mortality data from National Institute of Statistics in Spain, we analyzed trends of infectious disease mortality rates in Spain during 1980-2011 to provide information on surveillance and control of infectious diseases. During the study period, 628,673 infectious disease-related deaths occurred, the annual change in the mortality rate was -1.6%, and the average infectious disease mortality rate was 48.5 deaths/100,000 population. Although the beginning of HIV/AIDS epidemic led to an increased mortality rate, a decreased rate was observed by the end of the twentieth century. By codes from the International Classification of Diseases, 9th revision, the most frequent underlying cause of death was pneumonia. Emergence and reemergence of infectious diseases continue to be public health problems despite reduced mortality rates produced by various interventions. Therefore, surveillance and control systems should be reinforced with a goal of providing reliable data for useful decision making.

Background: The characteristics of respiratory tuberculosis (TB) favour the appearance of clusters of cases in space and time. It is important for public health authorities to know which clusters occur randomly and which merit further investigation., Objective: To detect spatial and spatio-temporal clusters of respiratory TB in Spain during the period from 1 January 2008 to 31 December 2010., Materials and Methods: Retrospective spatio-temporal study of respiratory TB cases reported to Spain's National Epidemiological Surveillance Network from 2008 to 2010, at a municipal level. We used the purely spatial and space-time Scan statistic estimators. All analyses were adjusted for age and sex., Results: The spatial cluster analysis detected 28 significant clusters and the spatio-temporal cluster analysis detected 20 significant clusters. The most likely spatial cluster comprised seven municipalities in the Greater Barcelona Area. Most space-time clusters were situated in the same area, and were detected between 1 April 2008 and 31 March 2009., Conclusion: The distribution of TB clusters as shown by the proposed models furnishes a spatial pattern of the distribution of the disease. The two methods used can be a useful tool for analysing the distribution of respiratory TB in Spain.

Objectives: To analyze the spatial pattern of legionellosis in Spain for men and women during the period 2003-2007 and to identify spatial clustering of risk., Methods: We identified the spatial pattern of the distribution of legionellosis rates based on calculation of rates by municipality through the direct method. Smoothing of these rates was performed by the Empirical Bayes method for studying the spatial pattern of disease for both sexes. We used Morańs index to analyze spatial autocorrelation rates globally. To calculate local rates, the Local Moran's Index [known as local indicators of spatial association (LISA)], was used to analyze the clusters of municipalities with the highest risk., Results: After smoothing the risk, the highest rates (over 50 per 100,000 inhabitants) were grouped in the eastern Mediterranean coastal areas and the north of the mainland, as well as in the Mediterranean islands. Moran's index smoothed rates were 0.15 for men and 0.23 for women. The spatial clusters of statistically significant higher rates calculated by the LISA index were distributed in the north and east for both sexes., Conclusions: These methods of spatial analysis allow patterns of disease distribution to be identified. All the methods used yielded similar results. These techniques are a complementary tool for epidemiological surveillance of infectious diseases., (Copyright © 2010 SESPAS. Published by Elsevier Espana. All rights reserved.)

Background: Tuberculosis incidence has been associated with many factors, both epidemiological and social. In Spain, tuberculosis is a statutorily notifiable disease requiring individualised reporting. During the last few years rates of respiratory tuberculosis show a steady decline. This study sought to assess respiratory tuberculosis morbidity and mortality in association to socio-economic and epidemiological covariates and estimate its spatial distribution across the country, using geo-statistical methods., Methods: Respiratory tuberculosis incidence rates were standardised by age and sex with the data of the National Epidemiological Surveillance Network (RENAVE, Red Nacional de Vigilancia Epidemiológica) for 2006. The following socio-economic variables were included in the study: socio-economic status, educational level, overcrowding rate, population density, standardised immigration rate by sex, unemployment rate and average spending per person in euros. The epidemiological variables included were, such as, AIDS rate and the influenza incidence rate. To assess the association of covariables a multivariate analysis was performed using a Generalised Linear Model assuming Poisson distribution. The goestatistical method co-kriging was adjusted with the significant variables to built the spatial distribution of risk., Results: The statistically significant covariates were overcrowding rate, standardised immigration rate by sex, educational level, unemployment rate, average spending per person in euros, AIDS rate and the influenza incidence rate. The geostatistical method shows spatial variability of the risk with higher risks in the northwest and southeast of the peninsula., Conclusion: Results prove that the co-kriging method is a useful tool to show the spatial distribution of risk. Alternatively, tuberculosis is associated with both social and epidemiological covariates.

Background: Oesophageal carcinoma is one of the most common cancers worldwide. Its incidence and mortality rates show a wide geographical variation at a world and regional level. Geographic mapping of age-standardized, cause-specific death rates at a municipal level could be a helpful and powerful tool for providing clues leading to a better understanding of its aetiology., Methods: This study sought to describe the geographic distribution of oesophageal cancer mortality for Spain's 8077 towns, using the autoregressive spatial model proposed by Besag, York and Mollié. Maps were plotted, depicting standardised mortality ratios, smoothed relative risk (RR) estimates, and the spatial pattern of the posterior probability of RR being greater than 1., Results: Important differences associated with area of residence were observed in risk of dying from oesophageal cancer in Spain during the study period (1989-1998). Among men, excess risk appeared across the north of the country, along a band spanning the length of the Cantabrian coastline, Navarre, the north of Castile & León and the north-west of La Rioja. Excess risk was likewise observed in the provinces of Cadiz and part of Seville in Andalusia, the islands of Tenerife and Gran Canaria, and some towns in the Barcelona and Gerona areas. Among women, there was a noteworthy absence of risk along the mid-section of the Cantabrian seaboard, and increases in mortality, not observed for men, in the west of Extremadura and south-east of Andalusia., Conclusion: These major gender- and area-related geographical differences in risk would seem to reflect differences in the prevalence of some well-established and modifiable risk factors, including smoking, alcohol consumption, obesity and diet. In addition, excess risks were in evidence for both sexes in some areas, possibly suggesting the implication of certain local environmental or socio-cultural factors. From a public health standpoint, small-area studies could be very useful for identifying locations where epidemiological research and intervention measures ought to receive priority, given the potential for reducing risk in certain places.