Adapting Schools to Climate Change with Green, Blue, and Grey Measures in Barcelona: Study Protocol of a Mixed-Method Evaluation.

Under the framework of the Urban Innovative Actions program of the European Commission, in 2020, 11 primary schools in Barcelona were transformed into climate shelters by implementing green, blue, and grey measures. Schoolyards were also opened to the local community to be used during non-school periods. Here we present the study protocol of a mixed-method approach to evaluate the effectiveness of the interventions in terms of improving environmental quality and health for users. We evaluated school level through the following: (1) quantitative pre-post quasi-experimental study, and (2) qualitative evaluation. The quantitative study included measures of (a) environmental variables (collected via low-cost and non-low-cost sensors), (b) students' health and well-being (collected via health questionnaires, attention levels test, and systematic observations), and (c) teachers' health and well-being (collected via thermal comfort measurements and health questionnaires). The qualitative methods evaluated the perceptions about the effects of the interventions among students (using Photovoice) and teachers (through focus groups). The impact of the interventions was assessed at community level during summer non-school periods through a spontaneous ethnographic approach. Data collection started in August 2019 and ended in July 2022. The evaluation provides the opportunity to identify those solutions that worked and those that need to be improved for future experiences, as well as improve the evaluation methodology and replication for these kinds of interventions.

Environmental drivers, climate change and emergent diseases transmitted by mosquitoes and their vectors in southern Europe: A systematic review.

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

Evidences supporting the inclusion of immigrants in the universal healthcare coverage.

In 2012, the Spanish government enforced a healthcare exclusion policy against undocumented immigrants. The newly elected government has recently derogated this policy. To analyze how this decree could have affected population health, we looked at primary health patients who would have been excluded and compared with a matched sample of non-excluded patients. Potentially excluded patients had decreased odds of: depression, chronic obstructive pulmonary disease, dyslipidaemia, heart failure and hypertension while diabetes mellitus rates were similar to non-excluded. Infectious diseases were more frequent in potentially excluded population (HIV, tuberculosis and syphilis). The exclusion of patients impedes the control of infectious diseases at a community level.

Does the economic recession influence the incidence of pertussis in a cosmopolitan European city?

BACKGROUND: In the last few years, pertussis has re-emerged worldwide. The aim of this article is to study how the incidence of the disease has evolved in Barcelona city over a 16-year period, and determine which factors are associated with the evolution of the disease. We discuss the causes of the observed changes considering different possibilities such as vaccination coverage, vaccine effectiveness, increased surveillance or the effect of the current economic recession. METHODS: We performed a cross-sectional, observational, population-based descriptive study using data for the 2000-2015 period from the notifiable diseases register maintained by Barcelona Public Health Agency. We used Poisson regression to compute adjusted odds ratios (aOR) and their corresponding 95% confidence intervals (CI). RESULTS: A total of 1791 cases were registered. The incidence of the disease increased throughout the city from 2011 onwards. While children under 1 year of age had the highest-incidence and were the most at risk (aOR = 27.18, CI:23.51-31.44), we found that the age of affected children was higher in the last years. Incidence proportion (PRR) was lower among foreign-born children than native children (PRR = 0.43 CI:0.32-0.58). In the whole-cell vaccine period (2000-2004), the percentage of cases under 1 year of age who received the vaccine was lower than in 2005-2015 when the acellular vaccine was used (p = 0.01), suggesting a lower efficacy of the acellular vaccine. However, vaccination coverage in children under 6 years remained high (~ 90%), and there were no significant year-to-year variations (p = 0.757). Moreover, there did not appear to be any significant restrictions in medical care. According to the index of disposable household income (DHI), pertussis incidence increased from 2011 onwards in all neighbourhoods and remained higher in those with lower DHI. CONCLUSIONS: The noteworthy increase in pertussis incidence does not seem to be due to the economic recession, but to other factors here described.

Prevalence of obesity and related factors in schoolchildren aged 3 to 4 years.

OBJECTIVE: To describe the prevalence of obesity and analyse possible differences in it according to sociodemographic characteristics, diet, physical activity, screen use and family perception of the weight and dietary habits of schoolchildren aged 3 to 4 years in Barcelona. METHODS: We conducted a cross-sectional study in a representative sample of schools selected based on the socioeconomic status (SES) of the corresponding neighbourhood and school ownership. We selected 101 schools in Barcelona and recruited pupils aged 3 to 4 years during the 2016-17 academic year (n = 2936 children). Anthropometric measurements were taken in each participant. Family members completed a questionnaire on eating habits, physical activity, sleeping hours, screen use and the family's perception of the child's weight and diet. The primary variable was the body mass index (BMI) for age and sex, subsequently categorised as normal weight, overweight or obese. RESULTS: Approximately 7.0% of girls and 7.1% of boys aged 3 to 4 years presented obesity. The prevalence of obesity (8.3%) was higher in neighbourhoods of lower SES compared to those of higher SES (5.2%; p = .004). Parents of children with obesity reported that the child had some excess weight or excess weight in 46.9% of cases, 3.9% indicated the child's weight was appropriate and 0.9% that the child was a little underweight or underweight (p < .001). DISCUSSION: The prevalence of obesity in children aged 3 to 4 years is high. There are social and geographical inequalities, and obesity was more prevalent in areas of lower SES. A large percentage of the families of children with obesity do not consider that the child's weight is excessive.

Evaluating the effect of passive cooling strategies in school buildings on children's well-being in Barcelona: A quasi-experimental, mixed methods study.

Passive cooling strategies were implemented in 11 school buildings in Barcelona within a pilot project to improve thermal conditions. The present study aimed to evaluate the intervention's impact on students' comfort and well-being at school. A quasi-experimental pre-post study based on mixed methods was conducted. Quantitative data were collected through self-reported questionnaires administrated to sixth-grade students in 21 schools (11 in an intervention group, IG, and 10 in a comparison group, CG). The authors measured changes in satisfaction with indoor temperature and indoor air quality (IAQ), the presence of bothering factors (temperature too high, temperature too low, unpleasant odours, and lighting problems), and students' well-being and performance. Difference-in-difference analysis was conducted to evaluate differences between the IG and CG in pre-post changes. Qualitative data were collected through photovoice-based sessions (59 sixth grade students) and interviews (7 teachers) in the IG. A thematic content analysis identified three main categories: changes in perceptions of indoor environmental conditions, indoor environment-related health and well-being, and indoor environment and their reported impact on learning. Quantitative findings show positive changes among the IG in perceived indoor temperature, air quality, and well-being at school, while suggest no significant changes in perceptions of temperature too low, lighting problems, and students' performance, in relation to the CG. Compared to the CG, students in the IG perceiving temperature too high significantly decreased among girls, while unpleasant odours decreased only among boys. In the qualitative assessment, participants reported that school transformations improved their indoor thermal and visual comfort, IAQ, and unpleasant odours. Participants also reported a reduction of fatigue, stress, irritability, and stifling sensation, as well as enhanced concentration. This study highlights the benefits of school passive design for student's comfort and well-being in Mediterranean climates and suggests the need to extend these interventions to other school buildings in similar contexts.

Threats and Interventions During the Treatment of Tuberculosis in an Inner-city District.

BACKGROUND: Since there are active drugs against tuberculosis (TB), the most effective control measures are to assure treatment adherence and to perform contact tracing. Given the long treatment duration and characteristics of some TB patients, threats that put at risk treatment adherence may appear. Identify and address them is essential to achieve the objectives of disease control. OBJECTIVES: To identify the epidemiological characteristics of TB patients and the incidents and threats occurring during treatment, to describe the interventions performed to enhance treatment adherence and to determine if there are differences among native and foreign-born patients in the TB clinical unit of a referral hospital in the inner city of Barcelona. METHODS: A descriptive, observational, cross-sectional study was performed. We recorded information on sociodemographic and clinical characteristics, incidents and interventions during treatment in all patients with TB diagnosed between September 2013 and August 2016. RESULTS: 172 patients were included, 62.2% were foreign-born. The most common incidents and threats were medication-related complications (43.0%), missed follow-up visits (34.3%), communication problems (25.6%), comorbidities complications (23.8%), trips (19.2%), fear of social rejection (16.9%) and change of address (14.5%). The adherence-promoting interventions were: follow-up calls, directly observed treatment, medical and humanitarian reports, extra visits and cultural mediation. Incidents and interventions were more frequent in foreign-born patients, however there were no differences in treatment success among Spanish and foreign-born. CONCLUSION: In this inner city several incidents occurred during TB treatment that can threaten adherence and are more common among foreign-born patients. Coordination among professionals from different healthcare settings was able to overcome obstacles in most cases and achieve TB treatment completion.

Three-Year Follow-Up of the POIBA Intervention on Childhood Obesity: A Quasi-Experimental Study.

Childhood obesity has increased worldwide over the past four decades. This quasi-experimental study aimed to assess the effectiveness of a multicomponent and multilevel school-based intervention (POIBA) at 3 years of follow-up. The nutrition intervention focused on food groups, food pyramid, nutrients, portions, and balanced menus. In total, 3624 children participated in the study. Anthropometric measurements and information on food frequency and behavior, physical activity, and daily screen use were collected in the intervention (IG) and comparison group (CG). Positive unadjusted changes toward adherence to recommendations were found for water, meat, sweets, and fried potato consumption, proper breakfast, not having dinner in front of the TV, out-of-school physical activity, and daily screen use. Three scores were used to calculate the proportion of children making more than one change to improve healthy habits regarding physical activity (global Activity score), nutrition (global Nutrition score), and both (global score). Students exposed to the intervention had a significantly better global Activity score (16.2% IG vs. 11.9% CG; p = 0.012) and Global score (63.9% IG vs. 58.5% CG; p = 0.025). Intervention effects on obesity incidence at 3-year follow-up lost significance but maintained the positive trend. In conclusion, school-based interventions including a family component could be useful to address the childhood obesity problem.

Organization of Tuberculosis Control in Spain: Evaluation of a Strategy Aimed at Promoting the Accreditation of Tuberculosis Units. / Organización del control de la tuberculosis en España: evaluación de una estrategia dirigida a fomentar la acreditación de unidades de tuberculosis.

INTRODUCTION: Well-coordinated multidisciplinary teams are essential for better tuberculosis (TB) control. Our objective was to evaluate the impact of Spanish Society of Pneumology (SEPAR) accreditation of TB Units (TBU) and to determine differences between the accredited and non-accredited centers. DESIGN: Observational descriptive study based on a self-administered survey from October 2014 to February 2018 completed by 139 heads of respiratory medicine departments collected by SEPAR, before and after TBU accreditation. VARIABLES: demographic, epidemiological and contact tracing (CT) variables, among others. ANALYSIS: basic descriptive analysis, and calculation of medians for continuous variables and proportions for categorical variables. The variables were compared using the Chi-squared test and logistic regression. RESULTS: The response rate was 54.7% and 43.2% in the pre- and post-TBU accreditation period, respectively. No differences were observed in the care and coordination variables between the pre- and post-accreditation survey, nor in the organization when only accredited centers were analyzed. When we compared the accredited and non-accredited centers, significant differences were detected in the collection of the final conclusion, management of resistance, coordination with other departments, contact tracing, and directly observed treatment. CONCLUSIONS: The approach of different professionals with regard to TB has been addressed. Positive aspects and areas for improvement have been detected, and better results were observed in the accredited versus non-accredited centers. A closer supervision of TBUs is necessary to improve their effectiveness.

Tuberculosis recurrences and predictive factors in a vulnerable population in Catalonia.

BACKGROUND: Patients with a history of tuberculosis (TB) have a high probability of recurrence because long-term cure is not always maintained in successfully treated patients. The aim of this study was to identify the probability of TB recurrence and its predictive factors in a cohort of socially vulnerable patients who completed treatment in the TB referral center in Catalonia, which acts as the center for patients with social and health problems. METHODS: This retrospective open cohort study included all patients diagnosed with TB who were admitted and successfully treated in Serveis Clínics between 2000 and 2016 and who remained disease-free for a minimum of 1 year after treatment completion. We calculated the incidence density of TB recurrences per person-years of follow-up. We also estimated the cumulative incidence of TB recurrence at 1, 2, 5, and 10 years of follow-up. Bivariate analysis was conducted using Kaplan-Meier curves. Multivariate analysis was conducted using Cox regression. Hazard ratios (HR) were calculated with their 95% confidence intervals (95%CI). RESULTS: There were 839 patients and 24 recurrences (2.9%), representing 0.49 per 100 person-years. The probability of a recurrence was 0.63% at 1 year of follow-up, 1.35% at 2 years, and 3.69% at 5 years. The multivariate analysis showed that the predictive factors of recurrence were age older than 34 years (aHR = 3.90; CI = 1.06-14.34 at age 35-45 years and aHR = 3.88; CI = 1.02-14.80 at age >45 years) and resistance to at least one anti-TB drug (aHR = 2.91; CI = 1.11-7.65). CONCLUSIONS: Attention should be paid to socially vulnerable persons older than 34 years with a previous episode of resistant TB. Surveillance resources should be directed toward adequately treated patients who nevertheless have a high risk of recurrence.

Tuberculosis incidence among infected contacts detected through contact tracing of smear-positive patients.

BACKGROUND: The contacts of people with pulmonary tuberculosis (PTB) have a high risk of becoming infected and developing tuberculosis (TB). Our aim was to determine the incidence of TB and its risk factors in a cohort of contacts with latent TB infection (LTBI) detected through contact tracing of smear-positive PTB cases. METHODS AND FINDINGS: We performed a population-based retrospective cohort study including contacts that had LTBI, and were contacts of people with PTB who started treatment between 2008 and 2014. We followed up contacts until they developed TB or until the end date for follow-up (31st December 2016). We used Kaplan-Meier curves to compute incidence at 2 and 5 years, and Cox regression to compute hazard ratios (HR) and their 95% confidence intervals (CI). We analyzed 3097 close contacts of 565 PTB cases. After exclusion of 81 co-prevalent TB cases, 953 contacts had LTBI, of which 14 developed TB. Their risk of developing TB after two and five years was 0.7% (CI: 0.3-1.6) and 1.8% (CI: 1.1-3.1) respectively. Contacts who had not been referred for LTBI treatment had a 1.0% (CI: 0.2-4.0) risk at 5 years. Risk of developing TB at 5 years was 1.2% (CI: 0.5-3.0) among people who completed treatment, and 11.1% (CI: 5.1-23.3) for those who did not. Risk factors for TB were not completing LTBI treatment (HR 9.4, CI: 2.9-30.8) and being female (HR 3.5, CI: 1.1-11-3). CONCLUSIONS: LTBI treatment plays a fundamental role in decreasing the risk of developing TB. It is necessary to achieve a maximum contact tracing coverage and the highest possible compliance with LTBI treatment.

Clinical Presentations and Outcomes Related to Tuberculosis in Children Younger Than 2 Years of Age in Catalonia.

Introduction: Children younger than 2 years have an increased risk of complications associated with tuberculosis (TB) due to the immaturity of the innate and adaptive immune response. We aimed to identify TB clinical presentations and outcomes as well as risk factors for complications in this age group. Materials and Methods: Multicenter, retrospective, cross-sectional study of TB cases in children aged <2 years in Catalonia (2005-2013). Epidemiological and clinical data were collected from the hospital medical records. TB complications, sequelae included, were defined as any tissue damage generating functional or anatomical impairment after being diagnosed or after TB treatment being completed. Statistical analyses were based on bivariate chi-square and multivariate logistic regression, and it was carried out with Stata® version 13.1. Odds ratios (OR) and its 95% confidence intervals were calculated (CI). Results: A total of 134 patients were included, 50.7% were male, the median [IQR] age was 13[8-18] months, and 18.7% (25/134) showed TB-associated complications. Pulmonary TB was diagnosed in 94.0% (126/134) of children, and the most common complications were lobar collapse (6/126). TB meningitis was diagnosed in 14/134 (10.4%), and hydrocephalus and mental impairment occurred in 1 and 2 patients, respectively. Two patients with spinal TB developed vertebral destruction and paraplegia, respectively. Only one of the patients died. At multivariate level, tachypnea (OR = 4.24; 95% CI 1.17-15.35) and meningeal (OR = 52.21; 95% CI 10.05-271.2) or combined/extrapulmonary forms (OR = 11.3; 95% CI 2.85-45.1) were associated with the development of TB complications. Discussion: TB complications are common in children under 2 years old. Extrapulmonary TB forms in this pediatric age remain a challenge and require prompt diagnosis and treatment in order to prevent them. The presence of tachypnea at the time of TB diagnosis is an independent associated factor to the development of TB complications in infants. This clinical sign should be closely monitored in patients in this age group. It is necessary to perform further studies in this age group in a prospective design in order to understand whether there are other factors associated to TB complications.

Threats and Interventions During the Treatment of Tuberculosis in an Inner-city District / Factores de riesgo e intervenciones durante el tratamiento de la tuberculosis en un barrio marginal

Background: Since there are active drugs against tuberculosis (TB), the most effective control measures are to assure treatment adherence and to perform contact tracing. Given the long treatment duration and characteristics of some TB patients, threats that put at risk treatment adherence may appear. Identify and address them is essential to achieve the objectives of disease control.Objectives: To identify the epidemiological characteristics of TB patients and the incidents and threats occurring during treatment, to describe the interventions performed to enhance treatment adherence and to determine if there are differences among native and foreign-born patients in the TB clinical unit of a referral hospital in the inner city of Barcelona.Methods: A descriptive, observational, cross-sectional study was performed. We recorded information on sociodemographic and clinical characteristics, incidents and interventions during treatment in all patients with TB diagnosed between September 2013 and August 2016.Results: 172 patients were included, 62.2% were foreign-born. The most common incidents and threats were medication-related complications (43.0%), missed follow-up visits (34.3%), communication problems (25.6%), comorbidities complications (23.8%), trips (19.2%), fear of social rejection (16.9%) and change of address (14.5%). The adherence-promoting interventions were: follow-up calls, directly observed treatment, medical and humanitarian reports, extra visits and cultural mediation. Incidents and interventions were more frequent in foreign-born patients, however there were no differences in treatment success among Spanish and foreign-born. (AU)

Antecedentes: Dado que existen medicamentos activos contra la tuberculosis (TB), las medidas de control más efectivas son asegurar la adherencia al tratamiento y realizar un seguimiento cercano. Debido a la larga duración del tratamiento y las características de algunos pacientes con TB, pueden entrar en juego ciertos factores que hacen peligrar la adherencia al tratamiento. Identificar estos factores y abordarlos es esencial para lograr los objetivos de control de la enfermedad.Objetivos: Identificar las características epidemiológicas de los pacientes con TB y los incidentes y factores que tienen lugar durante el tratamiento, describir las intervenciones realizadas para mejorar la adherencia al tratamiento y determinar si existen diferencias entre los pacientes nativos y extranjeros en la Unidad Clínica de TB de un hospital de referencia en el centro de la ciudad de Barcelona.Métodos: Se realizó un estudio descriptivo, observacional y transversal. Registramos las características sociodemográficas y clínicas de todos los pacientes con TB diagnosticados entre septiembre de 2013 y agosto de 2016, así como los incidentes y las intervenciones realizadas durante el tratamiento.Resultados: Se incluyeron 172 pacientes, el 62,2% eran nacidos en el extranjero. Los incidentes y los factores de riesgo más comunes fueron: complicaciones relacionadas con la medicación (43,0%), visitas de seguimiento perdidas (34,3%), problemas de comunicación (25,6%), complicaciones de las comorbilidades (23,8%), viajes (19,2%), miedo al rechazo social (16,9%) y cambio de domicilio (14,5%). Las intervenciones para el fomento de la adherencia fueron: llamadas de seguimiento, tratamiento directamente observado, informes médicos y humanitarios, visitas adicionales y mediación cultural. Los incidentes e intervenciones fueron más frecuentes en pacientes nacidos en el extranjero; sin embargo, no hubo diferencias en el éxito del tratamiento entre españoles y nacidos en el extranjero. (AU)

Organización del control de la tuberculosis en España: evaluación de una estrategia dirigida a fomentar la acreditación de unidades de tuberculosis / Organization of Tuberculosis Control in Spain: Evaluation of a Strategy Aimed at Promoting the Accreditation of Tuberculosis Units

INTRODUCCIÓN: Un buen control de la tuberculosis (TB) requiere disponer de personal multidisciplinario bien coordinado. El objetivo fue evaluar el impacto de la acreditación de unidades de TB (UTB) fomentada por la Sociedad Española de Neumología (SEPAR) y ver las diferencias entre los centros que se acreditaron y los que no. MATERIAL Y MÉTODOS: DISEÑO: Estudio observacional descriptivo basado en una encuesta autoadministrada entre octubre de 2014 y febrero de 2018 a 139 responsables de neumología registrados por SEPAR, antes y después de la acreditación. VARIABLES: demográficas, epidemiológicas y sobre estudio de contactos, entre otras. Análisis: descriptiva básica, cálculo de medianas para variables continuas y proporciones para categóricas. Se compararon las variables mediante el test chi-cuadrado y regresión logística. RESULTADOS: La tasa de respuesta fue del 54,7 y del 43,2% en el período pre- y postacreditación de UTB, respectivamente. No se observaron cambios en los diferentes ámbitos de atención y coordinación entre la encuesta pre- y postacreditación, ni tampoco en la organización, al analizar los centros acreditados. Al comparar los centros que se acreditaron con los que no, se detectaron diferencias significativas con relación a recogida de conclusión final, manejo de resistencias, coordinación con otros servicios, estudios de contactos o tratamiento directamente observado. CONCLUSIONES: Se ha objetivado cómo abordan la TB diferentes profesionales, se han detectado aspectos positivos y otros mejorables, y se han observando indicadores de mejor funcionamiento en los centros que se acreditaron frente a los que no lo hicieron. Se precisa una supervisión cercana de las UTB para mejorar su efectividad

INTRODUCTION: Well-coordinated multidisciplinary teams are essential for better tuberculosis (TB) control. Our objective was to evaluate the impact of Spanish Society of Pneumology (SEPAR) accreditation of TB Units (TBU) and to determine differences between the accredited and non-accredited centers. MATERIAL AND METHODS: Design Observational descriptive study based on a self-administered survey from October 2014 to February 2018 completed by 139 heads of respiratory medicine departments collected by SEPAR, before and after TBU accreditation. VARIABLES: demographic, epidemiological and contact tracing (CT) variables, among others. Analysis: basic descriptive analysis, and calculation of medians for continuous variables and proportions for categorical variables. The variables were compared using the Chi-squared test and logistic regression. RESULTS: The response rate was 54.7% and 43.2% in the pre- and post-TBU accreditation period, respectively. No differences were observed in the care and coordination variables between the pre- and post-accreditation survey, nor in the organization when only accredited centers were analyzed. When we compared the accredited and non-accredited centers, significant differences were detected in the collection of the final conclusion, management of resistance, coordination with other departments, contact tracing, and directly observed treatment