Exposure to residential traffic and trajectories of unhealthy ageing: results from a nationally-representative cohort of older adults.

BACKGROUND: Traffic exposure has been associated with biomarkers of increased biological ageing, age-related chronic morbidities, and increased respiratory, cardiovascular, and all-cause mortality. Whether it is associated with functional impairments and unhealthy ageing trajectories is unknown. METHODS: Nationally representative population-based cohort with 3,126 community-dwelling individuals aged ≥60 years who contributed 8,291 biannual visits over a 10 year period. Unhealthy ageing was estimated with a deficit accumulation index (DAI) based on the number and severity of 52 health deficits, including 22 objectively-measured impairments in physical and cognitive functioning. Differences in DAI at each follow-up across quintiles of residential traffic density (RTD) at 50 and 100 meters, and closest distance to a petrol station, were estimated using flexible marginal structural models with inverse probability of censoring weights. Models were adjusted for sociodemographic and time-varying lifestyle factors, social deprivation index at the census tract and residential exposure to natural spaces. RESULTS: At baseline, the mean (SD) age and DAI score of the participants were 69.0 (6.6) years and 17.02 (11.0) %, and 54.0% were women. The median (IQR) RTD at 50 and 100 meters were 77 (31-467) and 509 (182-1802) vehicles/day, and the mean (SD) distance to the nearest petrol station of 962 (1317) meters. The average increase in DAI (95%CI) for participants in quintiles Q2-Q5 (vs Q1) of RTD at 50 meters was of 1.51 (0.50, 2.53), 0.98 (-0.05, 2.01), 2.20 (1.18, 3.21) and 1.98 (0.90, 3.05), respectively. Consistent findings were observed at 100 meters. By domains, most of the deficits accumulated with increased RTD were of a functional nature, although RTD at 50 meters was also associated with worse self-reported health, increased vitality problems and higher incidence of chronic morbidities. Living closer to a petrol station was associated with a higher incidence of functional impairments and chronic morbidities. CONCLUSIONS: Exposure to nearby residential traffic is associated with accelerated trajectories of unhealthy ageing. Diminishing traffic pollution should become a priority intervention for adding healthy years to life in the old age.

Impact of the 2008 economic crisis on the burden of hepatitis B and C diseases in Southern European countries.

BACKGROUND: The economic crisis that began in 2008 has severely affected Southern (Greece, Italy, Portugal, Spain) Western European (SWE) countries of Western Europe (WE) and may have affected ongoing efforts to eliminate viral hepatitis. This study was conducted to investigate the impact of the economic crisis on the burden of HBV and HCV disease. METHODS: Global Burden of Diseases 2019 data were used to analyse the rates of epidemiological metrics of HBV and HCV acute and chronic infections in SWE and WE. Time series modelling was performed to quantify the impact of healthcare expenditure on the time trend of HBV and HCV disease burden in 2000-2019. RESULTS: Declining trends in incidence and prevalence rates of acute HBV (aHBV) and chronic HBV were observed in SWE and WE, with the pace of decline being slower in the post-austerity period (2010-2019) and mortality due to HBV stabilised in SWE. Acute HCV (aHCV) metrics and chronic HCV incidence and mortality showed a stable trend in SWE and WE, whereas the prevalence of chronic HCV showed an oscillating trend, decreasing in WE in 2010-2019 (p < 0.001). Liver cancer due to both hepatitis infections showed a stagnant burden over time. An inverse association was observed between health expenditure and metrics of both acute and chronic HBV and HCV. CONCLUSIONS: Epidemiological metrics for HBV and HCV showed a slower pace of decline in the post-austerity period with better improvement for HBV, a stabilisation of mortality and a stagnant burden for liver cancer due to both hepatitis infections. The economic crisis of 2008 had a negative impact on the burden of hepatitis B and C. Elimination of HBV and HCV by 2030 will be a major challenge in the SWE countries.

Assessing the effect of non-pharmaceutical interventions on COVID-19 transmission in Spain, 30 August 2020 to 31 January 2021.

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 (Rt) 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 Rt curve of each province to identify possible associations with global SI variations. We fitted and compared several generalised additive models using multimodel inference, to quantify the statistical effect on Rt of the global SI (stringency) and the individual SIs (separate effect of NPIs).ResultsThe global SI had a significant lowering effect on the Rt (mean: 0.16 ± 0.05 units for full stringency). Mandatory closing times for non-essential businesses, limited gatherings, and restricted outdoors seating capacities (negative) as well as curfews (positive) were the only NPIs with a significant effect. Regional mobility restrictions and limited indoors seating capacity showed no effect. Our results were consistent with a 1- to 3-week-delayed Rt as a response variable.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.

Cadmium (Cd) and Lead (Pb) topsoil levels and incidence of childhood leukemias.

There are few well-established risk factors for childhood leukemias. While the frequency of childhood leukemias might be partially attributable to some diseases (accounting for a small fraction of cases) or ionizing radiation, the role of heavy metals has not been assessed. The objective of our study was to assess the potential association between levels of cadmium (Cd) and lead (PB) in soil and childhood leukemias incidence. We conducted a population-based case-control study of childhood leukaemia in Spain, covering 2897 incident cases gathered from the Spanish Registry of Childhood Tumours and including 14 Spanish Regions with a total population of 5,307,433 children (period 1996-2015). Cd and Pb bioavailable levels at every children's home address were estimated using data from the Geochemical Atlas of Spain. We used logistic regression to estimate odds ratios (ORs) and their 95% confidence intervals (95%CIs); we included as covariates: sex, rurality, employment rate and socioeconomic status. Metal levels were analysed according to two definitions: as continuous variable assuming linearity and as categorical variables to explore a potentially nonlinear association (quantiles). Increases in both Cd and Pb topsoil levels were associated with increased probability of childhood leukemias incidence. The results for the models with the continuous variables showed that a unit increase on the topsoil level was associated with an OR of 1.11 for Cd (95%CI 1.00-1.24) and an OR of 1.10 for Pb (95%CI 0.99-1.21). Our study may point towards a possible link between residential Cd and Pb topsoil levels and the probability of childhood leukemias incidence. Residing in a location with the highest concentrations of these heavy metals compared to those locations with the lowest could increase the risk around a 20%, for both Cd and Pb.

Real time surveillance of COVID-19 space and time clusters during the summer 2020 in Spain.

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.

Approximate Bayesian inference for multivariate point pattern analysis in disease mapping.

We present a novel approach for analysing multivariate case-control georeferenced data in a Bayesian disease mapping context using stochastic partial differential equations (SPDEs) and the integrated nested Laplace approximation (INLA) for model fitting. In particular, we propose smooth terms based on SPDE models to estimate the underlying spatial variation as well as risk associated to pollution sources. Log-Gaussian Cox processes are used to estimate the intensity of the cases and controls, to account for risk factors and include a term to measure spatial residual variation. Each intensity is modelled on a baseline spatial effect (estimated from both controls and cases), a disease-specific spatial term and the effects of some covariates. By fitting these models, the residual spatial terms can be easily compared to detect high-risk areas not explained by the covariates. Three different types of effects to model exposure to pollution sources are considered on the distance to the source: a fixed effect, a smooth term to model non-linear effects by means of a discrete random walk of order one and a Gaussian process in one dimension with a Matérn covariance function. Spatial terms are modelled using a Gaussian process in two dimensions with a Matérn covariance function and are approximated using an approach based on solving an SPDE through INLA. Finally, this new framework is applied to a dataset of three different types of cancer and a set of controls from Alcalá de Henares (Madrid, Spain). Covariates available include the distance to several polluting industries and socioeconomic indicators. Our findings point to a possible risk increase due to the proximity to some of these industries.

Environment, lifestyle behavior and health-related quality of life in childhood and adolescent cancer survivors of extracranial malignancies.

BACKGROUND: Childhood cancer is a chronic disease with high survival rates. Childhood cancer survivors (CCS) can still face health effects later in their lives. Health-related quality of life (HRQoL) and the factors that modify it allow CCS and their families to improve care in the long-term follow-up. This study aims to: (1) examine the differences in HRQoL between CCS of extracranial malignancies and a comparison group, and (2) explore the clinical, environmental and lifestyles factors implicated in the HRQoL of CCS. METHODS: In this cross-sectional study with a case vs. non-case comparison, the HRQoL of 117 CCS between 8 and 18 years old was compared with healthy non-cases paired by sex and age. The Pediatric Environmental History (PEHis) was applied to obtain information on sociodemographic, clinical, environmental and lifestyle factors. The PedsQL™ Generic Core Scales questionnaire was used to evaluate HRQoL. RESULTS: In the multivariate analysis among the CCS, the following variables were significantly associated with HRQoL: Poor outdoor air quality (Total, Psychosocial, Emotional, Social and School domains); household income (Total, Psychosocial and School domains); and the presence of late effects (Total, Physical, Psychosocial, and Social domains); regular contact with nature (Physical domain); and the daily hours of screen-time (Emotional domain). CCS present HRQoL results superior to the non-cases group in the physical domain (86.10 vs. 80.34; p=0.001), finding no differences in the other domains evaluated. CONCLUSIONS: An environmental and community health approach, such as PEHis, in CCS long-term programs promoting the creation of healthier environments and lifestyles contributes to improving their HRQoL and secondarily other chronic diseases.

Secondhand smoke: A new and modifiable prognostic factor in childhood acute lymphoblastic leukemias.

BACKGROUND: The 5-year overall survival (OS) in childhood acute lymphoblastic leukemia (ALL) has reached 90% in high-income countries, levels that can no be longer overcome with strategies based on intensification of treatment. Other approaches in the search for new and modifiable prognostic factors are necessary to continue to improve these rates. The importance of environmental factors in the etiopathogenesis of childhood ALL has been regaining interest but its role in the prognosis and survival of this disease is not well explored. We aim to investigate the association between secondhand smoke (SHS) and survival in children diagnosed with ALL. METHODS: We analyzed survival rates in 146 patients under the age of 15 years diagnosed with ALL between January 1998 and May 2016 in the Region of Murcia, Spain. Evaluation of parental SHS and other known prognostic factors (sex, age, white blood cell count at diagnosis, cytogenetics, NCI/Rome Criteria, early response to therapy, and relapse) were assessed for impact on OS, event-free survival (EFS), cumulative incidence of relapse (CIR), and treatment-related mortality (CITRM) using Kaplan-Meier analysis, Cox regression, and Fine-Gray model. RESULTS: The mean follow-up time was 105.3 months (±66.5). Prenatal exposure to SHS due to parental smoking was highly prevalent. Of the mothers, 44.4% and 55.5% of the fathers smoked at some point during pregnancy. After the child's diagnosis of ALL 39.7% of mothers and 45.9% of fathers reported smoking. The Cox proportional hazards model showed that maternal smoking during pregnancy and after diagnosis (HR = 4.396, 95% CI: 1.173-16.474, p = 0.028); and relapse (HR = 7.919; 95% CI: 2.683-21.868; p < 0.001) are independent prognostic factors in determining survival. The Fine-Gray model showed that maternal smoking during pregnancy and after diagnosis (HR = 14.525, 95% CI: 4.228-49.90, p < 0.001) is an independent prognostic factor in CITRM. CONCLUSIONS: Persistent SHS worsens OS and TRM in children with ALL. This negative impact contributes to a different prognosis and may possibly provide an exceptional insight into new therapeutic approaches, including environmental aspects such as prevention and smoking cessation to improve survival outcomes.

Methodological approaches to the study of cancer risk in the vicinity of pollution sources: the experience of a population-based case-control study of childhood cancer.

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.

Industrial pollution and cancer in Spain: An important public health issue.

Cancer can be caused by exposure to air pollution released by industrial facilities. The European Pollutant Release and Transfer Register (E-PRTR) has made it possible to study exposure to industrial pollution. This study seeks to describe the industrial emissions in the vicinity of Spanish towns and their temporal changes, and review our experience studying industrial pollution and cancer. Data on industrial pollutant sources (2007-2010) were obtained from the E-PRTR registries. Population exposure was estimated by the distance from towns to industrial facilities. We calculated the amount of carcinogens emitted into the air in the proximity (<5km) of towns and show them in municipal maps. We summarized the most relevant results and conclusions reported by ecological E-PRTR-based on studies of cancer mortality and industrial pollution in Spain and the limitations and result interpretations of these types of studies. There are high amounts of carcinogen emissions in the proximity of towns in the southwest, east and north of the country and the total amount of emitted carcinogens is considerable (e.g. 20Mt of arsenic, 63Mt of chromium and 9Mt of cadmium). Although the emissions of some carcinogens in the proximity of certain towns were reduced during the study period, emissions of benzene, dioxins+furans and polychlorinated biphenyls rose. Moreover, the average population of towns lying within a 5km radius from emission sources of carcinogens included in the International Agency for Research on Cancer list of carcinogens was 9 million persons. On the other hand, the results of the reviewed studies suggest that those Spanish regions exposed to the pollution released by certain types of industrial facilities have around 17% cancer excess mortality when compared with those unexposed. Moreover, excess mortality is focused on digestive and respiratory tract cancers, leukemias, prostate, breast and ovarian cancers. Despite their limitations, ecological studies are a useful tool in environmental epidemiology, not only for proposing etiological hypotheses about the risk of living close to industrial pollutant sources, but also for providing data to account for situations of higher mortality in specific areas. Nevertheless, the reduction of emissions should be a goal, with special relevance given to establishing limits for known carcinogens and other toxic substances in the environs of population centers, as well as industry-specific emission limits.

Childhood cancer in small geographical areas and proximity to air-polluting industries.

AIM: Pediatric cancer has been associated with exposure to certain environmental carcinogens. The purpose of this work is to analyse the relationship between environmental pollution and pediatric cancer risk. METHOD: We analysed all incidences of pediatric cancer (<15) diagnosed in a Spanish region during the period 1998-2015. The place of residence of each patient and the exact geographical coordinates of main industrial facilities was codified in order to analyse the spatial distribution of cases of cancer in relation to industrial areas. Focal tests and focused Scan methodology were used for the identification of high-incidence-rate spatial clusters around the main industrial pollution foci. RESULTS: The crude rate for the period was 148.0 cases per 1,000,0000 children. The incidence of pediatric cancer increased significantly along the period of study. With respect to spatial distribution, results showed significant high incidence around some industrial pollution foci group and the Scan methodology identify spatial clustering. We observe a global major incidence of non Hodgkin lymphomas (NHL) considering all foci, and high incidence of Sympathetic Nervous System Tumour (SNST) around Energy and Electric and organic and inorganic chemical industries foci group. In the analysis foci to foci, the focused Scan test identifies several significant spatial clusters. Particularly, three significant clusters were identified: the first of SNST was around energy-generating chemical industries (2 cases versus the expected 0.26), another of NHL was around residue-valorisation plants (5 cases versus the expected 0.91) and finally one cluster of Hodgkin lymphoma around building materials (3 cases versus the expected 2.2) CONCLUSION: Results suggest a possible association between proximity to certain industries and pediatric cancer risk. More evidences are necessary before establishing the relationship between industrial pollution and pediatric cancer incidence.

Association between residential proximity to environmental pollution sources and childhood renal tumors.

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.

Residential proximity to environmental pollution sources and risk of rare tumors in children.

BACKGROUND: Few epidemiologic studies have explored risk factors for rare tumors in children, and the role of environmental factors needs to be assessed. OBJECTIVES: To ascertain the effect of residential proximity to both industrial and urban areas on childhood cancer risk, taking industrial groups into account. METHODS: We conducted a population-based case-control study of five childhood cancers in Spain (retinoblastoma, hepatic tumors, soft tissue sarcomas, germ cell tumors, and other epithelial neoplasms/melanomas), including 557 incident cases from the Spanish Registry of Childhood Tumors (period 1996-2011), and 3342 controls individually matched by year of birth, sex, and region of residence. Distances were computed from the residences to the 1271 industries and the 30 urban areas with ≥75,000 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 and socioeconomic confounders. RESULTS: Children living near industrial and urban areas as a whole showed no excess risk for any of the tumors analyzed. However, isolated statistical associations (OR; 95%CI) were found between retinoblastoma and proximity to industries involved in glass and mineral fibers (2.49; 1.01-6.12 at 3km) and organic chemical industries (2.54; 1.10-5.90 at 2km). Moreover, soft tissue sarcomas registered the lower risks in the environs of industries as a whole (0.59; 0.38-0.93 at 4km). CONCLUSIONS: We have found isolated statistical associations between retinoblastoma and proximity to industries involved in glass and mineral fibers and organic chemical industries.

Agricultural crop exposure and risk of childhood cancer: new findings from a case-control study in Spain.

BACKGROUND: Childhood cancer is the main cause of disease-related death in children in Spain. Although little is known about the etiology, environmental factors are potential explanations for a fraction of the cases. Previous studies have shown pesticides to be associated with childhood cancer. The difficulty of collecting personal environmental exposure data is an important limitation; this lack of information about pesticides motivates the development of new methods to subrogate this exposure. We developed a crop exposure index based on geographic information to study the relationship between exposure to different types of crops and risk of childhood tumors. METHODS: We conducted a population-based case-control study of childhood cancer covering 3350 cases and 20,365 controls in two Spanish regions. We used CORINE Land Cover to obtain data about agricultural land use. We created a 1 km buffer around every child and calculated the percentage of crop surface within the buffer (Global Crop Index) for total crops and for individual types of crops. We fitted mixed multiple unconditional logistic regression models by diagnostic group. RESULTS: We found excess of risk among children living in the proximity of crops. For total crops our results showed excesses of risk for almost all diagnostic groups and increasing risk with increasing crop index value. Analyses by region and individual type of crop also showed excess of risk. CONCLUSION: The results suggest that living in the proximity of cultivated land could be a risk factor for several types of cancer in children.

Childhood leukemia and residential proximity to industrial and urban sites.

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.

Time trends in municipal distribution patterns of cancer mortality in Spain.

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

Air quality modeling and mortality impact of fine particles reduction policies in Spain.

BACKGROUND: In recent years, Spain has implemented a number of air quality control measures that are expected to lead to a future reduction in fine particle concentrations and an ensuing positive impact on public health. OBJECTIVES: We aimed to assess the impact on mortality attributable to a reduction in fine particle levels in Spain in 2014 in relation to the estimated level for 2007. METHODS: To estimate exposure, we constructed fine particle distribution models for Spain for 2007 (reference scenario) and 2014 (projected scenario) with a spatial resolution of 16×16km(2). In a second step, we used the concentration-response functions proposed by cohort studies carried out in Europe (European Study of Cohorts for Air Pollution Effects and Rome longitudinal cohort) and North America (American Cancer Society cohort, Harvard Six Cities study and Canadian national cohort) to calculate the number of attributable annual deaths corresponding to all causes, all non-accidental causes, ischemic heart disease and lung cancer among persons aged over 25 years (2005-2007 mortality rate data). We examined the effect of the Spanish demographic shift in our analysis using 2007 and 2012 population figures. RESULTS: Our model suggested that there would be a mean overall reduction in fine particle levels of 1µg/m(3) by 2014. Taking into account 2007 population data, between 8 and 15 all-cause deaths per 100,000 population could be postponed annually by the expected reduction in fine particle levels. For specific subgroups, estimates varied from 10 to 30 deaths for all non-accidental causes, from 1 to 5 for lung cancer, and from 2 to 6 for ischemic heart disease. The expected burden of preventable mortality would be even higher in the future due to the Spanish population growth. Taking into account the population older than 30 years in 2012, the absolute mortality impact estimate would increase approximately by 18%. CONCLUSIONS: Effective implementation of air quality measures in Spain, in a scenario with a short-term projection, would amount to an appreciable decline in fine particle concentrations, and this, in turn, would lead to notable health-related benefits. Recent European cohort studies strengthen the evidence of an association between long-term exposure to fine particles and health effects, and could enhance the health impact quantification in Europe. Air quality models can contribute to improved assessment of air pollution health impact estimates, particularly in study areas without air pollution monitoring data.

Exposure to green spaces, cardiovascular risk biomarkers and incident cardiovascular disease in older adults: The Seniors-Enrica II cohort.

INTRODUCTION: The impact of residential green spaces on cardiovascular health in older adults remains uncertain. METHODS: Cohort study involving 2114 adults aged ≥ 65 years without cardiovascular disease (CVD), residing in five dense municipalities (Prince et al., 2015) of the Madrid region and with detailed characterization of their socioeconomic background, health behaviors, CVD biological risk factors, and mental, physical, and cognitive health. Greenness exposure was measured using the Normalized Difference Vegetation Index (NDVI) at varying distances from participants' homes. Traffic exposure, neighborhood environment, neighborhood walkability, and socioeconomic deprivation at the census level were also assessed. Serum N-terminal pro-B-type natriuretic peptide (NT-ProBNP), high-sensitivity troponin T (hs-TnT), interleukin 6 (IL-6), and Growth Differentiation Factor 15 (GDF-15) were measured at baseline, and incident CVD events identified through electronic medical records (International Classification of Primary Care-2 codes K74, K75, K77, K90, and K92). RESULTS: After adjusting for sex, age, educational attainment, financial hardship and socioeconomic deprivation at the census level, an interquartile range (IQR) increase in NDVI at 250, 500, 750, and 1000 m around participants' homes was associated with mean differences in ProBNP of -5.56 % (95 %CI: -9.77; -1.35), -5.05 % (-9.58; -0.53), -4.24 % (-8.19, -0.19), and -4.16 % (-7.59; -0.74), respectively; and mean differences in hs-TnT among diabetic participants of -8.03 % (95 %CI: -13.30; -2.77), -9.52 % (-16.08; -2.96), -8.05 % (-13.94, -2.16) and -5.56 % (-10.75; -0.54), respectively. Of similar magnitude, although only statistically significant at 250 and 500 m, were the observed lower IL-6 levels with increasing greenness. GDF-15 levels were independent of NDVI. In prospective analyses (median follow-up 6.29 years), an IQR increase in residential greenness at 500, 750, and 1000 m was associated with a lower risk of incident CVD. The variables that contributed most to the apparent beneficial effects of greenness on CVD were lower exposure to traffic, improved cardiovascular risk factors, and enhanced physical performance. Additionally, neighborhood walkability and increased physical activity were notable contributors among individuals with diabetes. CONCLUSION: Increased exposure to residential green space was associated with a moderate reduction in CVD risk in older adults residing in densely populated areas.

Pleural cancer mortality in Spain: time-trends and updating of predictions up to 2020.

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