Circulation and seasonality of influenza viruses in different transmission zones in Africa

Background

Influenza is responsible for more than 5 million severe cases and 290,000 to 650,000 deaths every year worldwide. Developing countries account for 99% of influenza deaths in children under 5 years of age. This paper aimed to determine the dynamics of influenza viruses in African transmission areas to identify regional seasonality for appropriate decision-making and the development of regional preparedness and response strategies.

Methods

We used data from the WHO FluMart website collected by National Influenza Centers for seven transmission periods (2013–2019). We calculated weekly proportions of positive influenza cases and determined transmission trends in African countries to determine the seasonality.

Results

From 2013 to 2019, influenza A(H1N1)pdm2009, A(H3N2), and A(H5N1) viruses, as well as influenza B Victoria and Yamagata lineages, circulated in African regions. Influenza A(H1N1)pdm2009 and A(H3N2) highly circulated in northern and southern Africa regions. Influenza activity followed annual and regional variations. In the tropical zone, from eastern to western via the middle regions, influenza activities were marked by the predominance of influenza A subtypes despite the circulation of B lineages. One season was identified for both the southern and northern regions of Africa. In the eastern zone, four influenza seasons were differentiated, and three were differentiated in the western zone.

Conclusion

Circulation dynamics determined five intense influenza activity zones in Africa. In the tropics, influenza virus circulation waves move from the east to the west, while alternative seasons have been identified in northern and southern temperate zones. Health authorities from countries with the same transmission zone, even in the absence of local data based on an established surveillance system, should implement concerted preparedness and control activities, such as vaccination.

Effect of emergency obstetric care and proximity to comprehensive facilities on facility-based delivery in Malawi and Haiti

Proximity of households to comprehensive obstetric care is a key determinant for preventing maternal mortality due to obstetric emergencies. The relationship between proximity to comprehensive care and facility delivery is further complicated by the use of varied methods in measuring facility obstetric capacity-which may misrepresent the real scenario of obstetric care availability in a service environment. We investigated the joint effects of proximity and two emergency obstetric care assessment (EmOC) methods on women's place of delivery in Malawi and Haiti. Household level and health facility data were obtained from the 2013-2018 Demographic and Health Surveys and Service Provision Assessment surveys. Records of women aged 15 to 49 years who had a childbirth in the last 5 years were linked to obstetric facilities within 5km, 10km and 15km from their households using Kernel Density Estimation. Log-binomial models were fitted to estimate the joint effects of proximity to comprehensive facilities on place of delivery and two EmOC methods (1. the facility's recent performance of signal functions only, and 2. a composite index of obstetric care), and whether this varied by urban/rural setting. Proximity to comprehensive facilities was significantly associated with facility delivery in Malawi among women living 5km of a comprehensive facility (using EmOC method 2), in addition, living further (15km) from facilities with high capacity of EmOC was associated with reduced likelihood for facility delivery in urban settings in stratified analyses. In contrast, positive associations were present in Haiti in both urban and rural settings, with the likelihood of facility delivery being higher with greater proximity of women to comprehensive facilities, regardless of methods to define EmOC. Women living within 5km of a comprehensive facility in Haiti were the most likely to deliver in facilities based on EmOC method 1 (APR: 1.81, 95% CI 1.56, 2.09). Findings from Malawi elucidates the relevance of context and suggests the need for research in diverse settings.

Birthweight of babies born to migrant mothers - What role do integration policies play?

Birthweights of babies born to migrant women are generally lower than those of babies born to native-born women. Favourable integration policies may improve migrants’ living conditions and contribute to higher birthweights. We aimed to explore associations between integration policies, captured by the Migrant Integration Policy Index (MIPEX), with offspring birthweight among migrants from various world regions. In this cross-country study we pooled 31 million term birth records between 1998 and 2014 from ten high-income countries: Australia, Belgium, Canada, Denmark, Finland, Japan, Norway, Spain, Sweden and United Kingdom (Scotland). Birthweight differences in grams (g) were analysed with regression analysis for aggregate data and random effects models.

Proportion of births to migrant women varied from 2% in Japan to 28% in Australia. The MIPEX score was not associated with birthweight in most migrant groups, but was positively associated among native-born (mean birthweight difference associated with a 10-unit increase in MIPEX: 105 g; 95% CI: 24, 186). Birthweight among migrants was highest in the Nordic countries and lowest in Japan and Belgium. Migrants from a given origin had heavier newborns in countries where the mean birthweight of native-born was higher and vice versa. Mean birthweight differences between migrants from the same origin and the native-born varied substantially across destinations (70 g–285 g).

Birthweight among migrants does not correlate with MIPEX scores. However, birthweight of migrant groups aligned better with that of the native-born in destination counties. Further studies may clarify which broader social policies support migrant women and have impacts on perinatal outcomes.

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Favourable migrant integration policies, as measured by the MIPEX, did not correlate with offspring birthweight among migrants.

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However, the MIPEX correlated with birthweight among the offspring of native-born women.

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Migrants' birthweights were higher in countries with high birthweights in the local population and vice versa.

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Birthweight among native-born seems to have a pull-effect on the birthweight of migrant groups.

International variations in the gestational age distribution of births: an ecological study in 34 high-income countries

Background

Few studies have investigated international variations in the gestational age (GA) distribution of births. While preterm births (22-36 weeks GA) and early term births (37-38 weeks) are at greater risk of adverse health outcomes compared to full term births (39-40 weeks), it is not known if countries with high preterm birth rates also have high early term birth rates. We examined rate associations between preterm and early term births and mean term GA by mode of delivery onset.

Methods

We used routine aggregate data on the GA distribution of singleton live births from up to 34 high-income countries/regions in 1996, 2000, 2004, 2008 and 2010 to study preterm and early term births overall and by spontaneous or indicated onset. Pearson correlation coefficients were adjusted for clustering in time trend analyses.

Results

Preterm and early term births ranged from 4.1% to 8.2% (median 5.5%) and 15.6% to 30.8% (median 22.2%) of live births in 2010, respectively. Countries with higher preterm birth rates in 2004-2010 had higher early term birth rates (r > 0.50, P < 0.01) and changes over time were strongly correlated overall (adjusted-r = 0.55, P < 0.01) and by mode of onset.

Conclusion

Positive associations between preterm and early term birth rates suggest that common risk factors could underpin shifts in the GA distribution. Targeting modifiable population risk factors for delivery before 39 weeks GA may provide a useful preterm birth prevention paradigm.

Reproductive history before and after HIV diagnosis: A cross-sectional study in HIV-positive women in Spain

The aim of this study is to examine the reproductive history of human immunodeficiency virus (HIV)-positive women, before and after HIV diagnosis, to describe the characteristics of women with pregnancies after HIV diagnosis, and to assess the prevalence of mother-to-child transmission.A cross-sectional study was performed among women within reproductive ages (18-49) selected from the cohort in the Spanish AIDS Research Network (CoRIS). A descriptive analysis of the pregnancy outcomes was made according to women's serostatus at the moment of pregnancy and association of women's characteristics with having pregnancy after HIV diagnosis was evaluated using logistic regression models.Overall, 161 women were interviewed; of them, 86% had been pregnant at least once and 39% after HIV diagnosis. There were 347 pregnancies, 29% of them occurred after HIV diagnosis and in these, 20% were miscarriages and 29% were voluntary termination of pregnancy. There were 3 cases of mother-to-child transmission among the 56 children born from HIV-positive mothers; in these cases, women were diagnosed during delivery. Having a pregnancy after HIV diagnosis was more likely when the younger women were at the time of diagnosis: odds ratio (OR) = 1.29 (95% confidence interval 0.40-4.17) for 25 to 29 years old, OR = 0.59 (0.15-2.29) for 30 to 34 years old, OR = 0.14 (0.03-0.74) for ≥35 years old, compared with those <25 years at diagnosis, who were diagnosed for ≥5 years (OR = 5.27 [1.71-16.18]), who received antiretroviral treatment at some point (OR = 9.38 [1.09-80.45]), and who received information on reproductive health (OR = 4.32 [1.52-12.26]).An important number of pregnancies occurred after HIV diagnosis, reflecting a desire for motherhood in these women. Reproductive and sexual health should be tackled in medical follow-ups.

Socioeconomic inequalities in stillbirth rates in Europe: measuring the gap using routine data from the Euro-Peristat Project

BACKGROUND

Previous studies have shown that socioeconomic position is inversely associated with stillbirth risk, but the impact on national rates in Europe is not known. We aimed to assess the magnitude of social inequalities in stillbirth rates in European countries using indicators generated from routine monitoring systems.

METHODS

Aggregated data on the number of stillbirths and live births for the year 2010 were collected for three socioeconomic indicators (mothers' educational level, mothers' and fathers' occupational group) from 29 European countries participating in the Euro-Peristat project. Educational categories were coded using the International Standard Classification of Education (ISCED) and analysed as: primary/lower secondary, upper secondary and postsecondary. Parents' occupations were grouped using International Standard Classification of Occupations (ISCO-08) major groups and then coded into 4 categories: No occupation or student, Skilled/ unskilled workers, Technicians/clerical/service occupations and Managers/professionals. We calculated risk ratios (RR) for stillbirth by each occupational group as well as the percentage population attributable risks using the most advantaged category as the reference (post-secondary education and professional/managerial occupations).

RESULTS

Data on stillbirth rates by mothers' education were available in 19 countries and by mothers' and fathers' occupations in 13 countries. In countries with these data, the median RR of stillbirth for women with primary and lower secondary education compared to women with postsecondary education was 1.9 (interquartile range (IQR): 1.5 to 2.4) and 1.4 (IQR: 1.2 to 1.6), respectively. For mothers' occupations, the median RR comparing outcomes among manual workers with managers and professionals was 1.6 (IQR: 1.0-2.1) whereas for fathers' occupations, the median RR was 1.4 (IQR: 1.2-1.8). When applied to the entire set of countries with data about mothers' education, 1606 out of 6337 stillbirths (25 %) would not have occurred if stillbirth rates for all women were the same as for women with post-secondary education in their country.

CONCLUSIONS

Data on stillbirths and socioeconomic status from routine systems showed widespread and consistent socioeconomic inequalities in stillbirth rates in Europe. Further research is needed to better understand differences between countries in the magnitude of the socioeconomic gradient.

Birth Outcomes of Latin Americans in Two Countries with Contrasting Immigration Admission Policies: Canada and Spain

Background

We delved into the selective migration hypothesis on health by comparing birth outcomes of Latin American immigrants giving birth in two receiving countries with dissimilar immigration admission policies: Canada and Spain. We hypothesized that a stronger immigrant selection in Canada will reflect more favourable outcomes among Latin Americans giving birth in Canada than among their counterparts giving birth in Spain.

Materials and Methods

We conducted a cross-sectional bi-national comparative study. We analyzed birth data of singleton infants born in Canada (2000–2005) (N = 31,767) and Spain (1998–2007) (N = 150,405) to mothers born in Spanish-speaking Latin American countries. We compared mean birthweight at 37–41 weeks gestation, and low birthweight and preterm birth rates between Latin American immigrants to Canada vs. Spain. Regression analysis for aggregate data was used to obtain Odds Ratios and Mean birthweight differences adjusted for infant sex, maternal age, parity, marital status, and father born in same source country.

Results

Latin American women in Canada had heavier newborns than their same-country counterparts giving birth in Spain, overall [adjusted mean birthweight difference: 101 grams; 95% confidence interval (CI): 98, 104], and within each maternal country of origin. Latin American women in Canada had fewer low birthweight and preterm infants than those giving birth in Spain [adjusted Odds Ratio: 0.88; 95% CI: 0.82, 0.94 for low birthweight, and 0.88; 95% CI: 0.84, 0.93 for preterm birth, respectively].

Conclusion

Latin American immigrant women had better birth outcomes in Canada than in Spain, suggesting a more selective migration in Canada than in Spain.

Gender equality and smoking: a theory-driven approach to smoking gender differences in Spain

BACKGROUND

The intersection between gender and class can aid in understanding gender differences in smoking.

AIM

To analyse how changes in gender inequality relate to differences in smoking prevalence by gender, education and birth cohort in Spain over the past five decades (1960-2010).

METHODS

The Gender Inequality Index (GII) was calculated in 5-year intervals from 1960 to 2010. GII ranges from 0 to 1 (1=highest inequality) and encompasses three dimensions: reproductive health, empowerment and labour market. Estimates of female and male smoking prevalence were reconstructed from representative National Health Surveys and stratified by birth cohort and level of education. We calculated female-to-male smoking ratios from 1960 to 2010 stratified by education and birth cohort.

RESULTS

Gender inequality in Spain decreased from 0.65 to 0.09 over the past 50 years. This rapid decline was inversely correlated (r=-0.99) to a rising female-to-male smoking ratio. The youngest birth cohort of the study (born 1980-1990) and women with high education levels had similar smoking prevalences compared with men. Women with high levels of education were also the first to show a reduction in smoking prevalence, compared with less educated women.

CONCLUSIONS

Gender inequality fell significantly in Spain over the past 50 years. This process was accompanied by converging trends in smoking prevalence for men and women. Smoking prevalence patterns varied greatly by birth cohort and education levels. Countries in earlier stages of the tobacco epidemic should consider gender-sensitive tobacco control measures and policies.

Varying gestational age patterns in cesarean delivery: an international comparison

Background

While international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups. Cesarean data presented by subgroups can be used to evaluate uptake of cesarean reduction policies or to monitor delivery practices for high and low risk pregnancies based on new scientific evidence. We studied differences and patterns in cesarean delivery rates by multiplicity and gestational age in Europe and the United States.

Methods

This study used routine aggregate data from 17 European countries and the United States on the number of singleton and multiple live births with cesarean versus vaginal delivery by week of gestation in 2008. Overall and gestation-specific cesarean delivery rates were analyzed. We computed rate differences to compare mode of delivery (cesarean vs vaginal birth) between selected gestational age groups and studied associations between rates in these subgroups namely: very preterm (26–31 weeks GA), moderate preterm (32–36 weeks GA), near term (37–38 weeks GA), term (39–41 weeks GA) and post-term (42+ weeks GA) births, using Spearman’s rank tests.

Results

High variations in cesarean rates for singletons and multiples were observed everywhere. Rates for singletons varied from 15% in The Netherlands and Slovenia, to over 30% in the US and Germany. In singletons, rates were highest for very preterm births and declined to a nadir at 40 weeks of gestation, ranging from 8.0% in Sweden and Norway, to 22.5% in the US. These patterns differed across countries; the average rate difference between very preterm and term births was 43 percentage points, but ranged from 14% to 61%. High variations in rate differences were also observed for near term versus term births. For multiples, rates declined by gestational age in some countries, whereas in others rates were similar across all weeks of gestation. Countries’ overall cesarean rates were highly correlated with gestation-specific subgroup rates, except for very preterm births.

Conclusions

Gestational age patterns in cesarean delivery were heterogeneous across countries; these differences highlight areas where consensus on best practices is lacking and could be used in developing strategies to reduce cesareans.

Disparities in pre-eclampsia and eclampsia among immigrant women giving birth in six industrialised countries

Objective

To assess disparities in pre-eclampsia and eclampsia among immigrant women from various world regions giving birth in six industrialised countries.

Design

Cross-country comparative study of linked population-based databases.

Setting

Provincial or regional obstetric delivery data from Australia, Canada, Spain and the USA and national data from Denmark and Sweden.

Population

All immigrant and non-immigrant women delivering in the six industrialised countries within the most recent 10-year period available to each participating centre (1995–2010).

Methods

Data was collected using standardised definitions of the outcomes and maternal regions of birth. Pooled data were analysed with multilevel models. Within-country analyses used stratified logistic regression to obtain odds ratios (OR) with 95% confidence intervals (95% CI).

Main outcome measures

Pre-eclampsia, eclampsia and pre-eclampsia with prolonged hospitalisation (cases per 1000 deliveries).

Results

There were 9 028 802 deliveries (3 031 399 to immigrant women). Compared with immigrants from Western Europe, immigrants from Sub-Saharan Africa and Latin America & the Caribbean were at higher risk of pre-eclampsia (OR: 1.72; 95% CI: 1.63, 1.80 and 1.63; 95% CI: 1.57, 1.69) and eclampsia (OR: 2.12; 95% CI: 1.61, 2.79 and 1.55; 95% CI: 1.26, 1. 91), respectively, after adjustment for parity, maternal age and destination country. Compared with native-born women, European and East Asian immigrants were at lower risk in most industrialised countries. Spain exhibited the largest disparities and Australia the smallest.

Conclusion

Immigrant women from Sub-Saharan Africa and Latin America & the Caribbean require increased surveillance due to a consistently high risk of pre-eclampsia and eclampsia.

Validation of a method for reconstructing historical rates of smoking prevalence

The validity of methods for reconstructing historical rates of smoking prevalence has not been assessed before. Our objective was to assess their validity. We reconstructed smoking prevalence rates for each calendar year from 1940 to 2007 for men and women in Spain, using data on ages of smoking initiation and cessation available in the Spanish National Health Surveys of 2003-2004 and 2006-2007. To assess the validity of the reconstruction, we computed the differences between the reconstructed smoking prevalence and the contemporary observed smoking prevalence measured in the Spanish National Health Surveys of 1987, 1993, 1995, 1997, and 2001. We also compared reconstructed smoking prevalence trends with 35-year lagged lung cancer mortality rates in Spain as a proxy for the real prevalence trends. Reconstructed smoking prevalence rates compared with contemporary measured rates showed small differences in men (between -2.1% and 2.1%) and an overestimation in women (between 2.0% and 5.7%). Reconstructed smoking prevalence trends were significantly correlated with lagged lung cancer mortality trends (P = 0.004 for men, P < 0.0001 for women). The reconstruction of smoking prevalence rates through this methodology offers a feasible tool with which countries lacking previous smoking surveys can understand historical trends in their tobacco epidemic, which aids in designing and implementing adequate tobacco control interventions.

HIV testing and counselling for migrant populations living in high-income countries: a systematic review

BACKGROUND

The barriers to HIV testing and counselling that migrants encounter can jeopardize proactive HIV testing that relies on the fact that HIV testing must be linked to care. We analyse available evidence on HIV testing and counselling strategies targeting migrants and ethnic minorities in high-income countries.

METHODS

Systematic literature review of the five main databases of articles in English from Europe, North America and Australia between 2005 and 2009.

RESULTS

Of 1034 abstracts, 37 articles were selected. Migrants, mainly from HIV-endemic countries, are at risk of HIV infection and its consequences. The HIV prevalence among migrants is higher than the general population's, and migrants have higher frequency of delayed HIV diagnosis. For migrants from countries with low HIV prevalence and for ethnic minorities, socio-economic vulnerability puts them at risk of acquiring HIV. Migrants have specific legal and administrative impediments to accessing HIV testing-in some countries, undocumented migrants are not entitled to health care-as well as cultural and linguistic barriers, racism and xenophobia. Migrants and ethnic minorities fear stigma from their communities, yet community acceptance is key for well-being.

CONCLUSIONS

Migrants and ethnic minorities should be offered HIV testing, but the barriers highlighted in this review may deter programs from achieving the final goal, which is linking migrants and ethnic minorities to HIV clinical care under the public health perspective.

Gestational age patterns of fetal and neonatal mortality in Europe: results from the Euro-Peristat project

Background

The first European Perinatal Health Report showed wide variability between European countries in fetal (2.6–9.1‰) and neonatal (1.6–5.7‰) mortality rates in 2004. We investigated gestational age patterns of fetal and neonatal mortality to improve our understanding of the differences between countries with low and high mortality.

Methodology/Principal Findings

Data on 29 countries/regions participating in the Euro-Peristat project were analyzed. Most European countries had no limits for the registration of live births, but substantial variations in limits for registration of stillbirths before 28 weeks of gestation existed. Country rankings changed markedly after excluding deaths most likely to be affected by registration differences (22–23 weeks for neonatal mortality and 22–27 weeks for fetal mortality). Countries with high fetal mortality ≥28 weeks had on average higher proportions of fetal deaths at and near term (≥37 weeks), while proportions of fetal deaths at earlier gestational ages (28–31 and 32–36 weeks) were higher in low fetal mortality countries. Countries with high neonatal mortality rates ≥24 weeks, all new member states of the European Union, had high gestational age-specific neonatal mortality rates for all gestational-age subgroups; they also had high fetal mortality, as well as high early and late neonatal mortality. In contrast, other countries with similar levels of neonatal mortality had varying levels of fetal mortality, and among these countries early and late neonatal mortality were negatively correlated.

Conclusions

For valid European comparisons, all countries should register births and deaths from at least 22 weeks of gestation and should be able to distinguish late terminations of pregnancy from stillbirths. After excluding deaths most likely to be influenced by existing registration differences, important variations in both levels and patterns of fetal and neonatal mortality rates were found. These disparities raise questions for future research about the effectiveness of medical policies and care in European countries.

Esophageal cancer risk by type of alcohol drinking and smoking: a case-control study in Spain

Background

The effect of tobacco smoking and alcohol drinking on esophageal cancer (EC) has never been explored in Spain where black tobacco and wine consumptions are quite prevalent. We estimated the independent effect of different alcoholic beverages and type of tobacco smoking on the risk of EC and its main histological cell type (squamous cell carcinoma) in a hospital-based case-control study in a Mediterranean area of Spain.

Methods

We only included incident cases with histologically confirmed EC (n = 202). Controls were frequency-matched to cases by age, sex and province (n = 455). Information on risk factors was elicited by trained interviewers using structured questionnaires. Multiple logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals (CI).

Results

Alcohol drinking and tobacco smoking were strong and independent risk factors for esophageal cancer. Alcohol was a potent risk factor with a clear dose-response relationship, particularly for esophageal squamous-cell cancer. Compared to never-drinkers, the risk for heaviest drinkers (≥ 75 g/day of pure ethanol) was 7.65 (95%CI, 3.16–18.49); and compared with never-smokers, the risk for heaviest smokers (≥ 30 cigarettes/day) was 5.07 (95%CI, 2.06–12.47). A low consumption of only wine and/or beer (1–24 g/d) did not increase the risk whereas a strong positive trend was observed for all types of alcoholic beverages that included any combination of hard liquors with beer and/or wine (p-trend<0.00001). A significant increase in EC risk was only observed for black-tobacco smoking (2.5-fold increase), not for blond tobacco. The effects for alcohol drinking were much stronger when the analysis was limited to the esophageal squamous cell carcinoma (n = 160), whereas a lack of effect for adenocarcinoma was evidenced. Smoking cessation showed a beneficial effect within ten years whereas drinking cessation did not.

Conclusion

Our study shows that the risk of EC, and particularly the squamous cell type, is strongly associated with alcohol drinking. The consumption of any combination of hard liquors seems to be harmful whereas a low consumption of only wine may not. This may relates to the presence of certain antioxidant compounds found in wine but practically lacking in liquors. Tobacco smoking is also a clear risk factor, black more than blond.

The contribution of a gender perspective to the understanding of migrants' health

In 2005 women represented approximately half of all 190 million international migrants worldwide. This paper addresses the need to integrate a gender perspective into epidemiological studies on migration and health, outlines conceptual gaps and discusses some methodological problems. We mainly consider the international voluntary migrant. Women may emigrate as wives or as workers in a labour market in which they face double segregation, both as migrants and as women. We highlight migrant women's heightened vulnerability to situations of violence, as well as important gaps in our knowledge of the possible differential health effects of factors such as poverty, unemployment, social networks and support, discrimination, health behaviours and use of services. We provide an overview of the problems of characterising migrant populations in the health information systems, and of possible biases in the health effects caused by failure to take the triple dimension of gender, social class and ethnicity into account.

Occupational risk factors in Alzheimer's disease: a review assessing the quality of published epidemiological studies

Epidemiological evidence of an association between Alzheimer's disease (AD) and the most frequently studied occupational exposures--pesticides, solvents, electromagnetic fields (EMF), lead and aluminium--is inconsistent. Epidemiological studies published up to June of 2003 were systematically searched through PubMed and Toxline. Twenty-four studies (21 case-control and 3 cohort studies) were included. Median GQI was 36.6% (range 19.5-62.9%). Most of the case-control studies had a GQI of <50%. The study with the highest score was a cohort study. Likelihood of exposure misclassification bias affected 18 of the 24 studies. Opportunity for bias arising from the use of surrogate informants affected 17 studies, followed by disease misclassification (11 studies) and selection bias (10 studies). Eleven studies explored the relationship of AD with solvents, seven with EMF, six with pesticides, six with lead and three with aluminium. For pesticides, studies of greater quality and prospective design found increased and statistically significant associations. For the remaining occupational agents, the evidence of association is less consistent (for solvents and EMF) or absent (for lead and aluminium).

Influence of age and geographical origin in the prevalence of high risk human papillomavirus in migrant female sex workers in Spain

OBJECTIVES

To estimate the prevalence and risk factors of high risk human papillomavirus (HPV) infection in migrant female sex workers (FSW) according to age and geographical origin.

METHODS

Cross sectional study of migrant FSW attending a sexually transmitted infection (STI) clinic in Madrid during 2002. Information on sociodemographic characteristics, reproductive and sexual health, smoking, time in commercial sex work, history of STIs, HIV, hepatitis B, hepatitis C, syphilis, and genitourinary infections was collected. High risk HPV Infection was determined through the Digene HPV Test, Hybrid Capture II. Data were analysed through multiple logistic regression.

RESULTS

734 women were studied. Overall HPV prevalence was 39%; 61% in eastern Europeans, 42% in Ecuadorians, 39% in Colombians, 29% in sub-Saharan Africans, and 24% in Caribbeans (p = 0.057). HPV prevalence showed a decreasing trend by age; 49% under 20 years, 35% in 21-25 years,14% over 36 years% (p<0.005). In multivariate analyses, area of origin (p = 0.07), hormonal contraception in women not using condoms (OR 19.45 95% CI: 2.45 to 154.27), smoking, age, and an interaction between these last two variables (p = 0.039) had statistically significant associations with HPV prevalence. STI prevalence was 11% and was not related to age or geographical origin.

CONCLUSIONS

High risk HPV prevalence in migrant FSW is elevated and related to age, area of origin, and use of oral contraceptives in women not using condoms. These data support the role of acquired immunity in the epidemiology of HPV infection and identifies migrant FSW as a priority group for sexual health promotion.

The availability of perinatal health indicators in Europe

This paper uses the results of the PERISTAT feasibility study to assess the extent to which the participating countries of Europe were able to provide data to construct the core and recommended indicators of perinatal health defined in the project. After describing the approaches used for data collection in participating countries, this paper describes the extent to which they were able to provide the data requested to construct the indicators. It documents data sources within each country and their characteristics. The paper then discusses influences on the agenda, particularly the extent to which data collection occurs as a by-product of other processes such as civil registration and the administration of health care and how these processes can both enable and impede data collection. It closes by suggesting how data collection in Europe can be improved in order to widen the scope of the agenda for compiling perinatal indicators.

False-positive tests for syphilis associated with human immunodeficiency virus and hepatitis B virus infection among intravenous drug abusers. Valencian Study Group on HIV Epidemiology

The role of HIV, hepatitis C virus, and hepatitis B virus infections in the production of biological false-positive reactions for syphilis was evaluated in two large samples of intravenous drug abusers and homosexual men attending AIDS prevention centers in Spain. A significantly increased odds ratio (OR) for false-positive tests for syphilis [OR 2.23, 95% confidence intervals (CI) 1.76-2.83] was observed for HIV-seropositive intravenous drug abusers; biological false-positive reactions were also more frequent (OR 1.73, 95% CI 1.30-2.31) among intravenous drug abusers who were hepatitis B virus seropositive but not among those who were hepatitis C virus seropositive (OR 0.90; 95% CI 0.48-1.69). Among homosexuals, the association between HIV and biological false-positive reactions was restricted to subjects who were also intravenous drug abusers, indicating the crucial role of intravenous drug abuse. Only 20.5% of intravenous drug abusers with a previous biological false-positive reaction yielded a false-positive result in their subsequent visit.

[Smoking reduces the biological capacity of conception. Results from a European multicenter study. The European Study Group on Infertility and Subfecundity]

The aim of the study was to examine the impact on subfecundity of male and female smoking at the start of a couple's waiting time to a planned pregnancy. Two types of designs were applied: a population based sample of women aged 25-44 years of age and a consecutive sample of pregnant women. Both studies were conducted within well-defined geographical regions in a number of European countries and data were collected by personal interviews in the population-based sample and by interview or self-administered questionnaires in the pregnancy study. A total of 10,665 couples participated in the study. Data on possible risk factors for infertility and subfecundity were collected at the start of the pregnancy planning, and fecundity was estimated by using time from the beginning of unprotected intercourse to a pregnancy, which survived at least 20 gestational weeks. Only couples who planned a pregnancy were included in the analyses. The results showed remarkably coherent associations between female smoking and subfecundity in each individual country and in all countries put together. In the population sample the odds ratio for subfecundity in the first pregnancy was 1.7 (95% c.l. 1.3-2.1 at the upper level of tobacco consumption) and during the most recent waiting time to pregnancy the odds ratio was 1.6 (95% c.l. 1.3-2.1). Results based on the pregnancy sample were similar with an odds ratio of 1.7 (95% c.l. 1.3-2.3). No significant association was found between male smoking and the couple's fecundity.

Repeating episodes of low fecundability. A multicentre European study. The European Study Group on Infertility and Subfecundity

Many reproductive failures tend to repeat themselves within the same couple. Whether fecundability (the probability of conceiving in a given number of menstrual cycles) follows the same pattern is studied using data from the European Studies on Infertility and Subfecundity (ESIS): 6630 women were interviewed on 'time to pregnancy' (TTP) and other aspects of their pregnancy history. Surveys were conducted between 1991 and 1994 in seven regions from five European countries. Furthermore, the pattern of fecundability in this population was compared with results from computer simulations based upon a population with fixed fecundability parameters. Results from ESIS speak in favour of the stability of fecundability in the relatively short reproductive life of a couple. However, a substantial proportion of couples with up to two events of subfecundability (TTP >9.5 months) became pregnant shortly after trying again. This finding calls for reservation in starting expensive and/ or unpleasant diagnostic procedures at an early stage when a couple tries to become pregnant again.

Does moderate alcohol intake reduce fecundability? A European multicenter study on infertility and subfecundity. European Study Group on Infertility and Subfecundity

BACKGROUND AND AIM

There are plausible reasons to suggest that heavy alcohol consumption reduces male as well as female fecundability, but only a few epidemiological studies have addressed this issue, and results concerning the effect of a moderate intake are equivocal. The present studies were designed to examine the association between male and female alcohol intake at the start of the waiting time to a planned pregnancy.

METHODS

Two types of studies were used-a population-based study of randomly selected women between 25 and 44 years in the different European countries from census registers and electoral rolls, and a pregnancy-based study of consecutive pregnant women (at least 20 weeks pregnant) recruited during prenatal care encounters. More than 4000 couples were included in each study, and 10 different regions in Europe took part in the data collection. Data were collected through personal interviews in all population-based samples and in all but four regions of the pregnancy study.

RESULTS

The results showed no strong nor coherent association between alcohol intake and subfecundity.

CONCLUSIONS

Should any causal effect be present it is restricted to females with a high intake of alcohol within the range of normal consumption reported in European countries.

Smoking reduces fecundity: a European multicenter study on infertility and subfecundity. The European Study Group on Infertility and Subfecundity

Several studies published within the past 10 years indicate that smoking reduces fecundity, but not all studies have found this effect, and smoking cessation is not used routinely in infertility treatment in Europe. The present study was designed to examine male and female smoking at the start of a couple's waiting time to a planned pregnancy. Two types of samples were used: population-based samples of women aged 25-44 years who were randomly selected in different countries from census registers and electoral rolls, in which the unit of analysis was the couple; and pregnancy-based samples of pregnant women (at least 20 weeks' pregnant) who were consecutively recruited during prenatal care visits, in which the unit of analysis was a pregnancy. More than 4,000 couples were included in each sample, and 10 different regions in Europe took part in data collection. The data were collected between August 1991 and February 1993 by personal interview in all population-based samples and in all but three regions of the pregnancy sample, where self-administered questionnaires were used. The results based on the population sample showed a remarkably coherent association between female smoking and subfecundity in each individual country and in all countries together, both with the first pregnancy (odds ratio (OR) = 1.7, 95% confidence interval (CI) 1.3-2.1, at the upper level of exposure) and during the most recent waiting time to pregnancy (OR = 1.6, 95% CI 1.3-2.1). Results based on the pregnancy sample were similar (OR = 1.7, 95% CI 1.3-2.3). No significant association was found with male smoking (in the population sample, OR = 0.9, 95% CI 0.7-1.1 (first pregnancy) and OR = 1.0, 95% CI 0.9-1.3 (most recent waiting time); in the pregnancy sample, OR = 0.9, 95% CI 0.7-1.1). The fecundity distribution among smokers appeared to be shifted toward longer waiting times without a change in the shape of the distribution. Women who have difficulty conceiving should try to stop smoking or to reduce their smoking to less than 10 cigarettes per day.

Prevalence of antibiotics to hepatitis C in a population of intravenous drug users in Valencia, Spain, 1990-1992

BACKGROUND

Hepatitis C has been related to other viral diseases such as the human immunodeficiency virus infection (HIV) or hepatitis B (HBV). The objective of this study was to estimate the prevalence and determinants of antibodies to hepatitis C virus (HCV) in intravenous drug users (IVDU) in Valencia (Spain) and to compare the seroprevalence between the HCV, HIV and HBV in this high risk group.

METHODS

A cross-sectional study was conducted in a sample of 1056 current IVDU from the Valencia area who attended the city's AIDS Information Centre between January 1990 and December 1992. Information on sociodemographic, sexual behaviour, and drug use variables was collected by means of a structured questionnaire. Antibodies to HCV, HIV and HBV were assayed by ELISA test.

RESULTS

The seroprevalence of HCV for the whole period was 85.5% (95% confidence interval [CI]: 83.2-87.5%), ranging from 76.5% in 1990 (95% CI: 71.9-81.1%) to 87.8% in 1992 (95% CI: 82.5-93.1%). Year of testing and prevalence of HBV markers showed an independent association with HCV seroprevalence. When only IVDU aged < 25 years were analysed, sharing of needles also appeared as an independent dominant. Of those IVDU with less than one year of addiction, 69% were HCV seropositive compared with 41% for HBV and 14% for HIV.

CONCLUSIONS

Intravenous drug users in Valencia showed one of the highest reported hepatitis C seroprevalences (85.5%). A more efficient parenteral transmission of hepatitis C virus than HBV or HIV is suggested.

Exposure to environmental tobacco smoke in nonsmoking pregnant women in relation to birth weight

The objective of this study was to determine whether birth weight is related to maternal exposure to environmental tobacco smoke. A cohort study was conducted in a sample of 710 nonsmoking women attending a prenatal education program in the third trimester of pregnancy in La Fe Hospital, Valencia, Spain. The duration of exposure to environmental tobacco smoke in the home, at work, and in vehicles and public places was collected by structured questionnaire. Cotinine levels were determined in saliva samples. Multiple regression was used to control for infant's sex and gestational age and for maternal age, height, prepregnancy weight, parity, education, social class, and episodic illnesses during pregnancy. The mean birth weight of infants of women with cotinine levels > 1.7 ng/ml was 87.3 g lower than that of infants of women with cotinine levels in the range 0-0.5 ng/ml (p = 0.048). Birth weight was negatively associated with average weekly duration of exposure in public places (p < 0.05), whereas mothers exposed to the partner's smoke for up to 14 hours/week had infants 177.2 g heavier than those of unexposed mothers. Although the evidence is weak for an effect of exposure to environmental tobacco smoke on the fetus of nonsmoking pregnant women, it may be sufficient to recommend restriction of smoking in enclosed work-and public places to reduce any risk of growth retardation.

Assessment of exposure to environmental tobacco smoke in nonsmoking pregnant women in different environments of daily living

The relation between duration of recent exposure to environmental tobacco smoke and salivary cotinine concentration was assessed in a cross-sectional study conducted during the third trimester of pregnancy of 710 nonsmoking women attending a prenatal clinic in La Fe Hospital, Valencia, Spain, between September 1, 1989, and September 30, 1991. A structured interview questionnaire was used to obtain information on duration of exposure to environmental tobacco smoke in the last 3 days to four sources: 1) partner's smoking at home, 2) others' smoking at home, 3) others' smoking at work, and 4) others' smoking in vehicles and in indoor public places. Cotinine levels were determined in saliva samples obtained during interviews. The duration of exposure to any source was positively related to cotinine levels independent of exposure to the other sources (p < 0.05). Self-reporting of the duration of recent exposure was a proxy measure of the integrated dose as assessed by saliva cotinine concentrations. The results underline the need to consider sources of exposure other than partner's tobacco smoke and to assess them individually rather than as an unweighted summative measure.

Epidemiology of hepatitis A in Valencia, Spain: public health implications

Between July 1988 and July 1989, sera from 1223 persons resident in the Valencia area of Spain were tested for antibodies against the hepatitis A virus. Sixty-five per cent of serum samples were positive for anti-HAV (95% confidence interval = 62.4-67.6). The prevalence of anti-HAV increased significantly with age (odds ratio > 50 years = 69.8; 95% confidence interval = 26.5-183.4) and previous history of hepatitis A (odds ratio = 2.1; 95% confidence interval = 1.4-3.2). Prevalence decreased with higher educational level (odds ratio, university studies = 0.2; 95% confidence interval = 0.1-0.5). Overall, there has been a reduction of anti-HAV prevalence reflecting the decreasing exposure of the Spanish population to hepatitis A virus in recent years, particularly in the younger generations. The age of infection has increased, increasing the probability of future epidemics in groups previously protected by immunity acquired in early childhood. This new epidemiological pattern has strong public health implications, and universal childhood vaccination together with measures directed to improve sanitation may be the best public health strategy to protect the population.

Reliability of the diagnosis of rheumatic conditions at the primary health care level

OBJECTIVE

To assess the reliability of the diagnosis given to rheumatic disease patients at the primary care level, the clinical records of 612 patients at the outpatient clinic of rheumatology of the main General Hospital in Alicante (Spain) were studied.

METHODS

The accuracy indices (sensitivity, specificity), the predictive values of tentative diagnosis made by the referring physicians and the degree of agreement (Kappa statistics) with the final diagnoses made by rheumatologists at the outpatient clinic of rheumatology were calculated.

RESULTS

There were differences in diagnosis agreement depending on the age of the referring doctor, with a greater degree of concordance among younger ones. More than 50% of the referral diagnoses were modified at the rheumatology outpatient clinic. In the most frequent diagnoses (inflammatory rheumatic diseases, osteoarthritis, soft tissue rheumatism) the level of concordance and the predictive values were low.

CONCLUSION

Our results highlight the need for upgrading courses in rheumatology for primary care physicians who have not been exposed to systematic training in rheumatology during their undergraduate studies. The epidemiological studies on rheumatic diseases based on primary care data should be interpreted with caution.

Sharing of injection equipment among 3755 intravenous drug users in Valencia, Spain, 1987-1992

BACKGROUND

In order to identify, in a sample of heroin intravenous drug users (IVDU), those factors associated with the predominant risk behaviour related to the transmission of HIV-1 infection--sharing of injection equipment--a cross-sectional survey was carried out in Valencia, Spain from 1987 to 1992.

METHODS

Informed consent and pertinent data were obtained from 3755 heroin IVDU recruited at two public AIDS Information Centres in two cities in the region of Valencia. Data were gathered on sociodemographic variables, and sexual and drug use behaviour by interview. The subjects were subsequently tested for HIV-1 antibody. A univariate analysis was carried out to identify variables that were significantly associated with sharing injection equipment. A logistic regression model was used to control for possible confounders.

RESULTS

The IVDU who were teenagers, prostitutes (OR = 1.95), who had antibodies to HIV-1 (OR = 1.30) or who had an IVDU steady partner were at significantly higher risk for sharing of injection equipment. Higher levels of education, condom use (OR = 0.65) and living in the smaller city (OR = 0.75) were inversely related to sharing injection equipment.

CONCLUSIONS

Our results suggest that different subgroups of IVDU have different characteristics that place them at different risk for HIV-1 infection. These characteristics should guide the design and intensity of specific preventive interventions. Teenagers and IVDU with low educational levels should be targetted for special attention by health authorities.

[The effect of moderate intake of alcohol during pregnancy on the weight of the newborn]

BACKGROUND

There is currently no doubt concerning the detrimental effects of the intake of high doses of alcohol during pregnancy. Nonetheless, there has been some controversy regarding the effects of intake of low or moderate quantities of alcohol. The aim of the present study, carried out within the framework of a more extensive European study (EUROMAC), was to specifically analyze the relation between moderate intake of alcohol in pregnant women and the weight of the newborns.

METHODS

A prospective cohort study including 1,005 women who attended prenatal consultation in the Hospital La Fe of Valencia between 12 and 18 weeks of pregnancy during 1989 was performed. All the subjects were asked on alcohol intake during the week prior to the interview with data on other sociodemographic and biologic variables being collected. Variance analysis was carried out to evaluate the association of the weight of the newborn with alcohol intake as well as with each of the control variables. Multiple lineal regression analysis was performed by the minimum squares method to evaluate possible effects of confusion and interaction.

RESULTS

Following adjustment for parity, weight of the mother prior to pregnancy, sex of the newborn, age at pregnancy and tobacco consumption, only a slight reduction in the weight of the newborns was observed in the category of intake greater than 90 g/week, however this difference was not statistically significant.

CONCLUSIONS

The low or moderate intake of alcohol during the first months of pregnancy has no detectable effect on fetal growth.

Smoking and drinking habits before and during pregnancy in Spanish women

STUDY OBJECTIVE

To investigate possible changes in smoking and drinking habits during pregnancy and to elucidate the sociodemographic factors associated with these changes in Spanish women.

DESIGN

A cross-sectional survey.

PARTICIPANTS AND SETTING

A total of 1004 pregnant women of between 12 and 18 weeks of gestation who were attending the antenatal clinic of the main regional hospital of Valencia (Spain) during 1989 were studied. All participants completed the study and only one eligible woman refused to participate when approached.

MEASUREMENTS AND MAIN RESULTS

Information was obtained by structured questionnaire (Euromac questionnaire), which included items on age, educational level, marital status, occupation, parity, previous and present smoking habits, and previous and present alcohol consumption. Women were asked about the consumption of cigarettes and alcohol for a typical week before they knew they were pregnant, and details of current consumption were obtained for the week before the interview. The number of drinks taken per week was later converted to the amount of absolute alcohol (in g). Sixty per cent of the women smoked and 72% drank alcohol before pregnancy. Forty eight per cent of smokers stopped smoking and 37% of drinkers stopped drinking alcohol during pregnancy. No sociodemographic factor showed an independent association with either smoking or drinking cessation. Only the number of cigarettes and the amount of alcohol consumed before pregnancy were identified as significant independent predictors for stopping.

CONCLUSIONS

Pregnant Spanish women seemed to stop smoking at about three times the rate found in Spanish women in the reproductive years. The sociodemographic variables usually associated with stopping smoking could not account for the high rate of quitting in these Spanish women, a rate higher than that in women from other developed countries. The high prevalence of smoking before pregnancy might explain not only the high rate of stopping smoking but also the absence of a well defined profile of "quitters". In our study, high levels of alcohol consumption were limited to a small group of pregnant women, and preventive efforts should be focused on this group.

Determinants of HIV-1 infection in intravenous drug users in Valencia, Spain, 1987-1991

From 1987 through 1991, 2687 intravenous drug users recruited at three AIDS information centres in the Region of Valencia (Spain) were interviewed about drug use and sexual behaviour and subsequently tested for HIV-1 antibody. The overall seroprevalence was high, 50% (95% confidence interval [CI]: 41.8-51.9%). There were no differences by gender, but HIV-1 infection was related to older age and city of residence. After adjustment by means of logistic regression age (odds ratio [OR] = 1.80), sharing of injection equipment (OR = 2.16), duration of addiction (OR = 6.59) and prostitution (OR = 1.77) were significantly associated with HIV-1 prevalence. High educational level was inversely related to HIV-1 status (OR = 0.43) and a decreasing trend of prevalence with time was observed.

[Work absenteeism of the nursing personnel of Valencia hospitals]

A survey was carried out on a sample of 973 nurses from hospitals in the Valencian Region. The objective was to study work absenteeism due to health reasons depending on socio-demographic factors, work organization and self perception of health status. Information was collected by means of a self-administered questionnaire. Duration and frequency of absenteeism was analysed over the previous twelve months. A 34.4% of female nurses and 35.4% of male nurses reported at least one episode, with an average length of 21 and 26 days respectively. There is a relation between absenteeism and self-perception of health status. We did not find man/woman differences with regards to absenteeism.

Shiftwork: its impact on the length and quality of sleep among nurses of the Valencian region in Spain

Previous research has shown the repercussions of shiftwork for workers' sleep. The objective of the present work is to evaluate the impact of shiftwork on the length and quality of sleep among nurses and on the intake of psychotropic drugs. A cross-sectional epidemiological study was carried out in 606 female nurses and 367 male nurses selected at random from the public hospitals in the Valencian region. Information was collected by means of a questionnaire. Univariate and multivariate statistical analysis techniques were used. For both female and male nurses, shiftwork led to a reduction in the length of sleep (by 2 h in those permanently on night shifts and by 30 min in those on a rotating night shift system) and an alteration in the quality of sleep (difficulty in sleeping, intermittent sleep, early waking, etc. occurred 10% more frequently), but it did not lead to an increase in the consumption of psychotropic drugs.

[Multiple codification of the causes of death: from dying "of" to dying "from"]

Multiple-cause mortality data is examined in the Valencian Region. In addition to coding the underlying cause of death (UCD), all causes of death which appeared mentioned on death certificates (MCD) were coded according to preliminary rules established by the Mortality Statistics Office. Specific diseases were selected to explore mortality patterns. The average number of conditions coded per death certificate was 2.7. Two or more conditions on the lowest used line appeared in 33.8% of all medical certificates. Septicaemia, high blood pressure and arteriosclerosis stand out among the conditions more often coded as MCD than coded as UCD. Exploring for mortality patterns a statistical association between coronary heart disease and diabetes emerged (p less than 0.0001). Multiple-cause mortality coding allow to discriminate mortality patterns and show a new magnitude to some specific causes of death.

Oesophageal cancer mortality: relationship with alcohol intake and cigarette smoking in Spain

STUDY OBJECTIVE

The aim of the study was to explore temporal changes in mortality from oesophageal cancer that could be related to tobacco and alcohol consumption.

DESIGN

The study used mortality trends from oesophageal cancer over the period 1951-1985. In addition, available trends on per capita consumption of alcohol and cigarettes are also presented.

SETTING

Data for this study were derived from Spain's National Institute for Statistics.

MAIN RESULTS

Age standardised mortality rates from oesophageal cancer have increased significantly among men in Spain from 1951 to 1985 (p less than 0.01). Mortality rates in women have not changed significantly during the same period, although there is evidence of a certain decrease in recent years. Trends of per capita cigarette consumption from 1957 to 1982 related positively with oesophageal cancer mortality among men, whereas no significant relationship was observed in women. Trends of beer, spirits, and total alcohol consumption were also positively correlated with oesophageal cancer mortality in men. Among women, a weaker relationship was found. Wine consumption showed no relationship with oesophageal cancer mortality either in men or women.

CONCLUSIONS

These results are similar to those found in other studies, supporting a role of alcohol (spirits and beer) and cigarette consumption in causation of oesophageal cancer. No relationship was observed with wine consumption.

Changing mortality patterns for major cancers in Spain, 1951-1985

Mortality trends for main cancer sites in Spain from 1951-1985 are presented. Age-standardized mortality rates per 100,000 were computed using the direct method. The Spanish population of 1970 was used as the standard. Age-standardized mortality rates for total cancer showed a marked increase among men throughout the period of study. This can be attributed mainly to the increase in lung cancer mortality (from 8.63 person-years to 44.74 between 1951 and 1985), which was only partially balanced by a reduction in the stomach cancer mortality (from 36.18 to 18.31). Among women the increase in total cancer is lower overall. It occurred mainly during the 1950s and thereafter the trend has remained stable and even declined in recent years. Lung cancer mortality rates among women have remained fairly stable and stomach cancer followed the same pattern as for men. Breast cancer mortality increased constantly during the period (from 7.21 to 19.38) but it was not until 1978 that it became the leading cause of cancer mortality among women.

Acute lymphoblastic leukaemia among Spanish children and mothers' occupation: a case-control study

STUDY OBJECTIVE

The aim was to investigate the association between mothers' occupational exposure during pregnancy and the incidence of acute lymphoblastic leukaemia in children.

DESIGN

The study was a case-control investigation. A face to face interview was used to assess exposures at work and relevant confounding variables.

SETTING

The study was community based and was carried out in five provinces of Spain.

SUBJECTS

128 cases less than 15 years of age were interviewed (91% of those eligible). Controls (one for each case) were chosen from the census lists and were matched on year of birth, sex and municipality.

MEASUREMENTS AND MAIN RESULTS

Children of mothers working at home had a relative risk (RR) of 7.0 (95% CI = 1.59-30.79) of developing acute lymphoblastic leukaemia. Exposure to organic dust was associated with a RR of 5.5 (95% CI = 1.21-24.8). There was a statistically significant interaction between exposure to organic dust and working at home. The majority of women working at home were hired by local industries to sew different types of tissues (cotton, wool, synthetic fibres) on a machine.

CONCLUSION

A similar association has not been reported before: if confirmed, this finding may suggest a new health concern.

Multiple sclerosis in Spain: an epidemiological study of the Alcoy health region, Valencia

Alcoy is a defined health region in eastern Spain, at 3 degrees E-38 degrees N, with a single neurology department and includes 33 towns with a total population of 133,915 inhabitants. We have evaluated the prevalence and incidence of multiple sclerosis (MS) by analysing this region. Six new cases have been detected (2.24/100,000/year) and the prevalence rate was 17.17/100,000, the highest in Spain at the moment. However, we found an irregular distribution in the different towns in so far that 15 of our 23 patients lived in a particular subregion, which means a prevalence of 44.59/100,000. Our study shows that the area of Alcoy is a medium MS risk region according to the thesis of Kurzke, although high MS areas may be found, thus confirming that MS distribution in southern Europe is not uniform.