Analysis of extrapulmonary tuberculosis in Spain: 2007-2012 National Study.

INTRODUCTION: This study sought to study the epidemiological characteristics of the extrapulmonary tuberculosis (EPTB) in relation to pulmonary tuberculosis (PTB) from 2007 to 2012 in Spain, and plot its trend across the same period. METHODS: We conducted an analytical cross-sectional study in which the following variables were analysed: age; sex; disease site; history of antituberculosis treatment; country of birth; presence of HIV infection; and culture results. Age-related differences were ascertained using the test of comparison of proportions, and crude and adjusted ORs were calculated using linear regression models. RESULTS: Of the total of 44,050 cases of tuberculosis reported in the period 2007-2012 and included in the study, 31,508 (71.53%) were pulmonary tuberculosis and 12,542 (28.47%) were EPTB. EPTB rates decreased across all age groups. The main EPTB risk factor was presence of HIV infection (OR 1.39). Persons aged under 65 years had a lower risk of EPTB. CONCLUSIONS: Although persons aged over 65 years displayed the highest incidence, there was nevertheless a downward trend across all age groups. Whereas children showed a significant decrease in tuberculous meningitis, this was not so for all extrapulmonary forms. EPTB rates among persons born outside Spain were much higher than those among the Spanish population.

[Epidemiology of hospitalizations for tuberculosis in Spain: analysis of minimum data set 1999-2009]. / Epidemiología de las hospitalizaciones por tuberculosis en España: análisis del conjunto mínimo básico de datos 1999-2009.

INTRODUCTION: The National Hospital Discharge Registry is a clinical-administrative database on hospital discharges, which is very useful at a regional level as a complementary source for surveillance. There are few national studies on tuberculosis (TB) using the National Hospital Discharge Registry, thus it was considered of interest to study the characteristics and trends of hospital discharges for TB in Spain. METHODS: A descriptive study was performed using the main variables in the National Hospital Discharge Registry (sex, age, main diagnosis, type of discharge, length of stay), and trend analysis of hospitalization rates per 100,000 population, as well as primary diagnosis, by sex, age group, and type of TB (pulmonary [TBP]/extrapulmonary [TBEP]), for the period 1999-2009 in Spain. RESULTS: A total of 65,609 hospital discharges were included in the study (66% male, 66% TBP, and 52% between 15-44 years). The overall rate of TB for the entire hospitalization period was 13.93 per 100,000 inhabitants, being 18.83 in males and 9.18 in females. The hospitalization rates for TBP and TBEP decreased in the period 1999-2009 in both sexes (TBP in males, from 18 to 13, and in females, from 8 to 6; TBEP in males from 4 to 3, and from 3 to 2 in female hospitalizations/100,000 habitants). In TBP, children are those with a smallest decline, and in TBEP there is an increase in males in all age groups from 2005. CONCLUSIONS: The results are consistent with those from surveillance. The slow decline in rates in children and the increase in extrapulmonary forms in males may be related to immigration, so it is necessary to improve TB monitoring in these groups.

[Space distribution of tuberculosis in Spain by geostatistical methods]. / Distribución espacial de la tuberculosis en España mediante métodos geoestadísticos.

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

[Zika virus infection: a new public health emergency with great media impact]. / La infección por virus Zika: una nueva emergencia de salud pública con gran impacto mediático.

Infection with Zika virus (ZV) has become a new epidemic, with great impact on the media, and is having a strong effect in Latin American countries. Its possible association with microcephaly and Guillain-Barré syndrome prompted the World Health Organization (WHO) to declare on 1 February 2016 that this epidemic is a public health emergency of international concern. Epidemiological data show an increasing incidence in countries like Brazil and Colombia, and that the epidemic is still expanding in many other countries. Between January 2007 and 27 April 2016, the WHO detected transmission in 55 countries (in 42 of these, this was the first outbreak of Zika) and 1,198 microcephalies and other neurological disorders in Brazil. Also, during 2015-2016, 13 countries detected an increase in Guillain-Barré syndrome and/or confirmation of ZV associated with Guillain-Barré syndrome. Research has already demonstrated a causal relationship between microcephaly and other serious brain disorders in newborns and ZV infection in the mother. Clinically, many cases are asymptomatic and it can be difficult to distinguish this diagnosis from that of other arboviruses. Vector control in Spain is a priority because of the presence of the Aedes albopictus (tiger mosquito). Early diagnosis is recommended, as is avoiding travel to endemic areas and unprotected sex, and ensuring that the high political profile, which can prevent this epidemic from becoming a high prevalence endemic disease, does not cause us to forget about other health problems.

[Risk Factors for Potentially Unsuccessful Results and Mortality during Tuberculosis Treatment in Spain]. / Factores de riesgo asociados a los resultados potencialmente insatisfactorios y a la mortalidad durante el tratamiento antituberculoso en España.

BACKGROUND: Successful result of treatment in 85% of cases is the target of a Tuberculosis (TB) Control Programme. The aim of this study is to determine the risk factors for unsuccessful completion of treatment and deaths of TB cases in Spain. METHODS: Data from the National Surveillance Epidemiological Network. Retrospective study including 5,880 TB cases reported in 2012. Outcomes were classified as: successful (S: cured and treatment completed), potentially unsuccessful (PU: failed, transferred, defaulted, still on treatment and unknown) and deaths. Logistic regression analysis was used to explore the association between epidemiological and clinical factors with PU and deaths as outcome variables. Two different models for nationals and foreigners were adjusted. RESULTS: Successful outcome was 81% in nationals and 79% in foreigners. Spanish TB cases had higher mortality rates than foreigners (8% vs. 2%), and lower percentage of transfers (2% vs. 6%). At multivariate level the risk factors for PU in nationals were: HIV coinfection (OR 1.6 CI95% 1.09-2.29) and previous treatment (OR 2.4 CI95% 1.67-3.53); and HIV coinfection (OR 1.7 CI95% 1.15-2.60), male sex (OR 1.4 CI95% 1.11-1.83) and pulmonary TB (OR 1.6 CI95% 1.22-2.09) in foreigners. Risk factors for death in nationals were: HIV coinfection (OR 2.7 CI95% 1.63-4.54), male sex (OR 1.4 CI95% 1.09-1.89), pulmonary TB (OR 1.5 CI95% 1.13-1.95) and an increasing risk with age (OR 8.9 CI95% 5.16-15.67 in over 45 years group.).; and HIV coinfection (OR 3.2 CI95% 1.53-6.76), male sex (OR 2.2 CI95% 1.01-4.60) and older age (OR 3.4 CI95% 1.81-6.48 in over 45 years group.) in foreigners. CONCLUSION: The rate of successful treatment in Spain does not meet the international target, especially in foreigners. To reduce unsuccessful treatment and deaths it is necessary to improve management in TB-HIV co-infected cases, and those with previous treatment story, pulmonary TB, males and older age.

Tularemia Outbreaks and Common Vole (Microtus arvalis) Irruptive Population Dynamics in Northwestern Spain, 1997-2014.

During the last decades, large tularemia outbreaks in humans have coincided in time and space with population outbreaks of common voles in northwestern Spain, leading us to hypothesize that this rodent species acts as a key spillover agent of Francisella tularensis in the region. Here, we evaluate for the first time a potential link between irruptive vole numbers and human tularemia outbreaks in Spain. We compiled vole abundance estimates obtained through live-trapping monitoring studies and official reports of human tularemia cases during the period 1997-2014. We confirm a significant positive association between yearly cases of tularemia infection in humans and vole abundance. High vole densities during outbreaks (up to 1000 voles/hectare) may therefore enhance disease transmission and spillover contamination in the environment. If this ecological link is further confirmed, the apparent multiannual cyclicity of common vole outbreaks might provide a basis for forecasting the risk of tularemia outbreaks in northwestern Spain.

Long-term molecular surveillance of multidrug-resistant tuberculosis in Spain.

The data presented here span 11 years (1998-2008) of monitoring of multidrug-resistant tuberculosis (MDR-TB) clustering through molecular typing techniques in Spain. The molecular and epidemiological data of 480 multidrug-resistant Mycobacterium tuberculosis complex isolates were analyzed. Thirty-one clusters involving 157 (32.7%) patients were identified. The proportion of immigrants increased substantially over the study period reaching 65% in 2008; however, the clustering rate remained stable indicating that local transmission was little influenced by imported MDR-TB. The three major clusters respond to the persistence of two autochthonous strains throughout the study period and an extensively drug-resistant (XDR) Mycobacterium bovis outbreak with only two cases was reported since 2002. Molecular and epidemiological evidence for the importation of new strains and their spread within the community was found. Immigrant-only clusters most often grouped patients infected abroad with strains belonging to rare spoligotypes. Conversely, widespread spoligotypes of the Latin-American and Mediterranean (LAM) and Haarlem families were responsible for the majority of the MDR-TB local transmission. The demonstration of clusters spanning several Spanish regions that have been ongoing throughout the study period makes it advisable to maintain a continuous molecular surveillance in order to monitor the spread of MDR-TB.

[Epidemiology of childhood tuberculosis in Spain: 2005-2009]. / Epidemiología de la tuberculosis pediátrica en España, 2005-2009.

BACKGROUND: European recent data about paediatric tuberculosis point out the importance of evaluate the trends of the disease to study the recent transmission, as well as the necessity of improving the microbiological diagnosis in paediatric cases. The aim of this paper is to study the epidemiology and trend evolution of paediatric tuberculosis in Spain during the period 2005-2009 and to establish the epidemiological differences between adult and paediatric tuberculosis. METHODS: Data reported to the National Surveillance Net (Red Nacional de Vigilancia Epidemiológica) in Spain was checked. Lineal regression was developed to establish the trend of the disease in all, adult and paediatric cases. Bivariate and multivariate logistic regression was used to compare paediatric and adult cases reported in 2009 and estimate the influence of different factors in the development of the disease. RESULTS: A total 39775, 2690 paediatrics (6.76%) cases of tuberculosis were reported during 2005-2009 period. Paediatric tuberculosis rates showed a slight increasing tendency (y=0.15x+7.8), while adult rates decrease during the period (y=-0.28x+20.2). In 2009, rates were 8.1 and 18.3 cases/100,000 inhab. for children and adults respectively. Paediatric cases presented higher proportion of pulmonary locations (84% vs. 76% in adults) and lower percentages of cases confirmed by culture (51% vs. 82% in adults) and of cases in non-Spanish population (25% vs. 34%). CONCLUSIONS: Paediatric tuberculosis rates showed a slight increasing tendency, while global and adult rates decrease slightly during the period. Tuberculosis disease shows different epidemiology in children and adults, what it is important to take into account to design public heh interventions.