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Having a proper understanding of the impact of influenza is a fundamental step towards improved preventive action. This paper reviews findings from the Burden of Acute Respiratory Infections study on the burden of influenza in Iberia, and its potential underestimation, and proposes specific measures to lessen influenza's impact. [ABSTRACT FROM AUTHOR]

Introduction: Mortality after radical cystectomy (RC) varies widely in the literature. In cohort studies, mortality rates can vary from as low as 0.5% in large-volume academic centers (2) to as high as 25% in developing countries series. This study aims to perform a systematic review of population-based studies reporting mortality after RC. Methods: A Systematic search was performed in Medline (PubMed®), Embase, and Cochrane for epidemiologic studies reporting mortality after RC. Institutional cohorts and those reporting mortality for specific groups within populations were excluded. Case series and non-epidemiologic series were also excluded. The aim of this review is to evaluate in-hospital mortality (IHM), 30-day mortality (30M), and 90-day mortality (90M). Results: Systematic search resulted in 42 papers comprising 449,661 patients who underwent RC from 1984 to 2017. Mean age was 66.1. Overall IHM, 30M, and 90M were 2.6%, 2.7%, and 4.9%, respectively, with 90M being 2.6 times higher than IHM on average. Lowest IHM was found in Canada and Australia (0.2% and 0.6%, respectively), while the highest IHM was 7.8% (Brazil). Canada and Spain showed the highest 90M (6.5%). 159,584 urinary diversions were analyzed, being mostly ileal conduits (76.8%). Conclusions: The majority of the studies available are from major developed economies with paucity of data in the developing world. 90M after RC tends to be at least twice as high as IHM. The knowledge of such epidemiologic data is vital to guide public policies, such as centralization, in order to reduce mortality. [ABSTRACT FROM AUTHOR]

38.5% of the Spanish working population reports pain, 5.1% severe pain. Pain is associated with a high utilization of health services, but, more importantly, with a significant reduction in the ability to continue their work performance. Interventions to minimize the significant costs inflicted by pain should be implemented. Objective: The objective of this paper is to provide an overview of the epidemiology of pain in the Spanish working population and to investigate the incremental costs of the different levels of pain on medical costs and productivity losses. Methods: This is a cross-sectional study of costs of pain in the Spanish working population from a societal perspective using data from a national representative survey. Results: Data from the 9919 respondents were analyzed. The prevalence of reported pain was 38.5%: 21.9% mild or very mild; 11.5% moderate; 5.1% severe or extreme. Increased self-reported pain was independently associated with significant increases in direct and indirect costs. Those reporting severe or extreme pain showed excess annual costs of €5118.97 per case, being 85% indirect costs. Conclusions: Spain is paying a heavy price for the high prevalence of pain in its working population. [ABSTRACT FROM AUTHOR]

The three European countries included in the northwest littoral of the Mediterranean region – Italy, France and Spain – reported their first cases of the SARS-CoV-2 coronavirus early in 2020. The subsequent epidemic strongly impacted these countries, challenging the healthcare systems efficiency, and the capacity and transparency of their public statistics structures. Because public statistics were not fully adapted to such a new health situation, the available official data could not wholly describe the epidemic correctly. This paper developed an indicator derived from the prevalence of SARS-CoV-2 aiming to describe the time and spatial dynamics of the epidemic. Although the analysis was not applied to France due to the lack of data available, the comparative analysis among Spain and Italy highlighted some similarities and certain divergences, partially attributable to the features of each country‘s national demographic patterns and the peculiarities of applied health protocols. Finally, mortality during the first wave of the epidemic has been analysed for the three countries, demonstrating higher mortality index in Spain, although the reported number of SARS-CoV-2 declared deaths does not explain a portion of this mortality excess. [ABSTRACT FROM AUTHOR]

This paper analyzes the detrimental effects on human rights of the Covid-19 in Spain and the necessary reaction of the legal instruments of the Rule of Law. [ABSTRACT FROM AUTHOR]

Objectives: This paper focuses on the issue of intimate partner violence and, specifically, on the distribution of femicides over time and the existence of copycat effects. This is the subject of an ongoing debate often triggered by the social alarm following multiple intimate partner homicides (IPHs) occurring in a short span of time. The aim of this research is to study the evolution of IPHs and provide a far-reaching answer by rigorously analyzing and searching for patterns in data on femicides. Methods: The study analyzes an official dataset, provided by the system VioGén of the Secretaría de Estado de Seguridad (Spanish State Secretariat for Security), including all the femicides occurred in Spain in 2007-2017. A statistical methodology to identify temporal interdependencies in count time series is proposed and applied to the dataset. The same methodology can be applied to other contexts. Results: There has been a decreasing trend in the number of femicides per year. No interdependencies among the temporal distribution of femicides are observed. Therefore, according to data, the existence of copycat effect in femicides cannot be claimed. Conclusions: Around 2011 there was a clear change in the average number of femicides which has not picked up. Results allow for an informed answer to the debate on copycat effect in Spanish femicides. The planning of femicides prevention activities should not be a reaction to a perceived increase in their occurrence. As a copycat effect is not detected in the studied time period, there is no evidence supporting the need to censor media reports on femicides. [ABSTRACT FROM AUTHOR]

What is already known about this subject There is an association between adiposity levels and physical activity guidelines for adolescents., Achieving physical activity recommendations helps adolescents to prevent obesity status., What this study adds This paper presents an association between physical activity levels and obesity status., This paper supports physical activity recommendations to avoid children's obesity levels., This paper emphasizes vigorous physical activity for this matter., Background There is no information about physical activity (PA) recommendations to avoid children's obesity levels and how much of vigorous PA (VPA) is included into the '60 minutes of MVPA 5 days a week' recommendation for children. Objective The aim of this study was to examine the association between PA and adiposity in children and to examine whether the current PA guidelines are associated with a low risk of having excess of body fat in children, with special focus on sex differences, and PA intensity. Methods A sample of 439 Spanish children aged 8-10 years from the European Youth Heart Study participated in the study. The variables measured were anthropometric characteristics (height, weight, body mass index [ BMI], skin-folds and waist circumference) and PA was measured during 6 consecutive days using the GT1M accelerometer. Results Receiver operating characteristic analysis showed significant cut-off points associated with non-overweight: 45 min d−1 of VPA and 67 min d−1 of moderate-to-vigorous physical activity ( MVPA) (using BMI categories); and non-fat: 41 min d−1 of VPA and 67 min d−1 of MVPA (using percentage of body fat) and 38 min d−1 of VPA and 47 min d−1 of MVPA (using waist circumference categories) for boys. For girls, the optimal cut-offs of moderate-to-vigorous activity and MVPA associated with non-overweight were 24 and 57 min d−1, respectively ( BMI). Boys who did not meet 67 min in MVPA had an increased risk of being overweight + obese and overfat + obese (odds ratio [ OR] = 2.48, 95% confidence interval [ CI] = 1.36, 4.53, and OR = 2.56, 95% CI = 1.12, 5.82). Conclusions The findings support current PA recommendations (60 min d−1 of MVPA) to avoid excess of body fat in Spanish children. However, VPA appears to be an important component for the prevention of obesity, and our findings suggest that PA recommendations should specify the dose of VPA required for optimal health. Therefore, public health PA recommendations should incorporate specifically a greater dose of VPA into the total amount of MVPA in 8- to 10-year-old boys. [ABSTRACT FROM AUTHOR]

Sport injury is a widely extended morbidity condition. However, epidemiological studies are far from giving a convergent outlook. Moreover, there is a lack of studies comparing relative risks of different groups of sports. The present paper is aimed to carry out a descriptive epidemiological study of sport injuries of athletes from 25 sport modalities in order to identify risk factors as well as to compare epidemiological characteristics according to the different sport groups. A sample of 297 athletes from different sport federations in the region of Madrid (Spain) were assessed using a protocol comprising a section about the sport being practiced and a section about injury incidence. Due to the wide variety of sport modalities, the sample was classified into four groups according to the Blázquez and Hernández Moreno's (1984) sports classification. Results showed no gender but age differences in injury incidence. They also showed differences in terms of injury frequency and severity (elapsed time between the injury and the returning to sport practice) among sport groups, being athletes practicing co-operation-opposition sports those who seemed to be more at risk. There were also differences regarding internal/external causes and when the injury was sustained. The global exposure injury rate (training and competition) rose to 4.1 injuries/1.000 hours. [ABSTRACT FROM AUTHOR]

Tuberculosis ( TB), a chronic disease caused by infection with the Mycobacterium tuberculosis complex, is endemic in wild boar ( Sus scrofa) and red deer ( Cervus elaphus) in south-central Spain. Understanding the temporal dynamics of this chronic infection requires long time series data collection over large areas. The aim of this paper was to identify the determinants of TB prevalence and severity in both species in Ciudad Real province, Spain, from 2000 to 2012. Study variables included management, population dynamics, and a range of geographical and climatological factors. The prevalence of TB in wild boar increased from 50% to 63% since the study commenced. This may be due to an increased hunting bag (a proxy for population abundance), which was correlated with TB infection rates. Low rainfall (a stochastic factor) was associated with higher individual risk of TB presence and progression, resulting in an increased proportion of severe cases of wild boar TB in dry years. This was probably a result of increased food restriction leading to a higher susceptibility to TB. In contrast, red deer TB showed an apparent stable trend, which may be a consequence of the species' higher and stable population size. Hunting management, characterized by fencing, was associated with a higher risk of TB in both wild boar and red deer, suggesting that intensive hunting management may have contributed to exacerbated TB figures. This difference was more marked in red deer than in wild boar, probably because fencing imposes less restriction on movement, population mixing and TB spread to wild boar than to deer. Our findings on TB dynamics are fundamental for assessing the impact of future disease-control actions (e.g. field vaccination). Moreover, such control plans must operate in the long term and cover large areas. [ABSTRACT FROM AUTHOR]

Objectives This paper examines the awareness and use of nonoccupational HIV post-exposure prophylaxis ( nPEP) in Spain, and the factors that influence this awareness. Methods Between June 2009 and July 2010, a mobile unit offered free, rapid HIV tests in a number of Spanish cities. A total of 2545 people were passively recruited and tested, and answered a self-administered questionnaire containing sociodemographic, behavioural and nPEP-related questions. Bivariate and multivariate analyses were performed, stratifying by gender/sexual behaviour. Results Some 34% of the responders were men who have sex with men ( MSM), 30% were men who have sex exclusively with women ( MSW), and 35% were women. Approximately 26% were foreigners, 46% had a university degree, and 51% had previously taken an HIV test. Overall, 22% were aware of nPEP. Only 2% had ever used it; 70% of these after high-risk sexual intercourse. Awareness was higher among MSM (34%) than women (16%) and MSW (15%). Multivariate analysis showed a lack of nPEP awareness to be associated with being born in Latin America, while awareness increased with the number of previous HIV tests among women and MSW. In MSM, awareness was also associated with having a university degree, the degree of interaction with gay culture, number of partners, and use of the internet as the main way of meeting partners. Conclusions nPEP awareness in the studied population was unacceptably low. The promotion of its availability should be made a major objective of prevention programmes, as a complementary measure to condom use. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of this paper is to explore the prevalence of psychiatric morbidity in different immigrant groups in Spain. In keeping with prior studies carried out in Europe, it is expected that the immigrant population will have elevated levels of psychopathology, with some variation across immigrant groups. Method: Design: Multicenter, observational, cross-sectional study. Setting: Primary care settings of two Spanish regions. Sample: N=1.503 immigrants paired with the same number of Spanish controls, adjusted by gender and age. Variables: Demographic variables, MINI International Neuropsychiatric Interview and Standardized Polyvalent Psychiatric Interview, somatic symptoms section. Student''s t tests, ORs and logistic regressions were used to analyze the data. Results: No differences in psychiatric morbidity were found (native born 30.9%, population vs. immigrants 29.6%, OR=.942, CI=.806–1.100) when comparing immigrants to native born Spaniards. Relative to Spaniards (30.9%), Latin American immigrants had significantly higher levels of psychopathology (36.8%), Sub-Saharan Africans (24.4%) and Asians (16%) had significantly lower levels, and Eastern Europeans (31.4%) and North Africans (26.8%) showed no significant difference. Conclusions: The hypotheses were only partially supported. Although overall immigrants did not differ from the native born population, when analyzed by geographic origin, only Latin Americans had higher levels of psychopathology. It is concluded that multiple factors need to be taken into consideration when studying the mental health of immigrants given that different immigrant groups have different levels of psychopathology. [Copyright &y& Elsevier]

This paper aims to identify the inter-relationships between the social factors that influence epidemiological patterns in the city neighbourhood of Casablanca, Zaragoza (Spain). Data for a cross-sectional survey were collected between January 2008 and April 2008 from a representative random sample of 1032 residents aged more than 15 years. The study interview contained information scales on healthcare behaviours, treatment evaluation, the number of medical consultations in the weeks pervious to the interview and the perceived health status of the respondents, using The Health Perception Questionnaire. The global index (continuous variable) allowed inferences to be made on the individual's perception of his/her own health. The assessment of social vulnerability was based on the occupational, educational and economic conditions of the interviewees. An individual was considered to belong to a vulnerable subeconomic group if he/she had a personal income of 6000 euros or less; or had no formal education or had been educated up to primary school level only; or was not in paid employment at the time of the interview. A descriptive and comparative analysis of the vulnerable and non-vulnerable population groups for perceived and diagnosed health variables was undertaken using parametric and non-parametric tests. A total of 550 interviewees (53.3%) were considered vulnerable people. Low level of instruction (primary or no education) was the main characteristic of this group (356 subjects, 64.7% of those identified as vulnerable). Binary logistic regression was used to analyse the association between belonging to the vulnerable group and a number of health variables adjusted for gender, age and area of residence. The vulnerable group had worse levels of perceived health even when controlled for gender and area of residence. In Casablanca, the place of residence is an important social stratification indicator reflected in the characteristics of the vulnerable population group and its perceived health. [ABSTRACT FROM AUTHOR]

Background: Records kept as a result of the implementation of Integrated Pollution Prevention and Control (IPPC) and the European Pollutant Release and Transfer Register (E-PRTR) constitute a public inventory of industries, created by the European Commission, which is a valuable resource for monitoring industrial pollution. Our objective is to ascertain whether there might be excess colorectal cancer mortality among populations residing in the vicinity of Spanish industrial installations that are governed by the IPPC Directive and E-PRTR Regulation and report their emissions to air. Methods: An ecological study was designed to examine colorectal cancer mortality at a municipal level (8098 Spanish towns), over the period 1997-2006. We conducted an exploratory "near vs. far" analysis to estimate the relative risks (RR) of towns situated at a distance of less than 2 km from industrial installations. The analysis was repeated for each of the 24 industrial groups. RR and their 95% credible/confidence intervals (95%CI) were estimated on the basis of Poisson regression models, using two types of modelling: a) the conditional autoregressive Bayesian model proposed by Besag, York and Mollié, with explanatory variables; and b) a mixed regression model. Integrated nested Laplace approximations were used as a Bayesian inference tool. Results: Statistically significant RRs were detected in the vicinity of mining industry (RR 1.258; 95%CI 1.082 - 1.463), paper and wood production (RR 1.071; 95%CI 1.007 - 1.140), food and beverage sector (RR 1.069; 95%CI 1.029 - 1.111), metal production and processing installations (RR 1.065; 95% CI 1.011 - 1.123) and ceramics (RR 1.050 ; 95% CI 1.004 - 1.099). Conclusions: Given the exploratory nature of this study, it would seem advisable to check in other countries or with other designs, if the proximity of industries that emit pollutants into the air could be an added risk factor for colorectal cancer mortality. Nevertheless, some of the differences between men and women observed in the analyses of the industrial groups suggest that there may be a component of occupational exposure, little-studied in the case of cancers of the digestive system. [ABSTRACT FROM AUTHOR]

Please cite this paper as: del Rosal et al. (2011) Pandemic H1N1 influenza-associated hospitalizations in children in Madrid, Spain. Influenza and Other Respiratory Viruses 5(6), e544-e551. Objective To describe the epidemiological and clinical characteristics of children hospitalized with 2009 pandemic influenza (pH1N1) in Madrid, Spain. Patients/Methods We included patients less than 14 years of age admitted to one of 18 hospitals in Madrid, Spain, between May 1 and November 30, 2009 and diagnosed with pH1N1 by polymerase chain reaction. A retrospective chart review was conducted and data were compared by age, presence of high-risk medical conditions, and pediatric intensive care unit (PICU) admission. Results A total of 517 pH1N1 cases were included for final analysis. One hundred and forty-two patients (27·5%) had predisposing underlying illnesses, with immunosuppression (36 children, 7%) and moderate persistent asthma (34, 6·6%) being the most common ones. Patients with underlying medical conditions had longer hospital stays [median 5, interquartile range (IQR) 3-8 days, versus median 4, IQR 3-6, P < 0·001] and required intensive care (20·4% versus 5·9%, P < 0·001) and mechanical ventilation more frequently than previously healthy children. Globally, intensive care was required for 51 patients (10%) and invasive mechanical ventilation for 12 (2%). Pediatric intensive care unit admission was significantly associated with abnormal initial chest X-ray [Odds Ratio (OR) 3·5, 95% confidence interval (CI) 1·5-8·5], underlying neurological condition (OR 3·1, CI 1·2-7·5) and immunosuppression (OR 2·9, 1·2-6·8). Five patients (0·9%) died; two with severe neurological disease, two with leukemia, and one with a malignant solid tumor. Conclusions Children with underlying medical conditions experienced more severe pH1N1 disease. Risk factors for admission to the PICU included underlying neurological conditions, immunosuppression and abnormal initial chest X-ray. [ABSTRACT FROM AUTHOR]

Giardia is the most common enteric protozoan that can be pathogenic to both humans and animals. Transmission can be direct through the faecal-oral route, or through ingestion of contaminated water or food. Genetic characterization of Giardia duodenalis isolates has demonstrated the existence of seven groups (assemblages A to G) which differ in their host distribution. Assemblages A and B are present in humans and other primates, dogs, cats, rodents, and other species of wild mammals, but the role of the different host animals in the epidemiology of human infection remains unclear. With this preliminary data, we can infer that nonhuman primates (NHP) might be a potential reservoir for zoonotic transmission. This research paper discusses the presence of Giardia in nonhuman primates housed in two Spanish zoological gardens (located in Valencia and Madrid). Twenty faecal samples obtained from 16 different species of NHP were studied; 70% were positives to Giardia, and genetic analyses were performed by sequencing of four genes (SSrRNA, glutamate dehydrogenase, triose phosphate isomerase, and beta-giardin). The assemblage A was the most frequent (63.4%) in the species studied. A sequence from a red ruffed lemur (corresponding to genotype AI) was obtained, and this is the first reported sequence of a gdh gene obtained from this species. The multi-locus sequence analysis was also performed on the samples positive to nested PCR belonging to assemblage B. After amplification using the GDHeF, GDHiF, and GDHiR gdh primers; AL3543, AL3546, AL3544, and AL3545 tpi primers; G7, G759, GBF, and GBR bg primers, amplicons of 432, 500, and 511 bp respectively were obtained. Amplification products were sequenced and the sequence and phylogenetic analyses showed that genotype IV like was the most frequent in the samples belonging to this assemblage. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of the effectiveness of a tobacco use prevention and control course on health sciences students' smoking prevalence and incidence. Background. Although it is known that the intervention of health professionals in their patients' tobacco use can be affected by their own habit, very few studies have analysed the effect of specific tobacco-oriented training on smoking among health science students. Methods. This study is a quasi-experimental study of community intervention. During the years 2005-2008, a total of 290 health science students on the intervention campus and 256 on the control campus took part in the study. In the former, the intervention consisted of a course on the prevention and control of tobacco use for students, which was not offered on the control campus. Data about tobacco use and socio-demographic variables were collected by means of a questionnaire before and 6 months after the intervention. Results. Prevalence of tobacco use decreased in the intervention group (-1.1%) and increased in the control group (1.5%). The risk of acquiring the habit was almost three times higher in the control group than in the intervention group and the probability of cessation was 40% higher in the intervention group and correlated with nicotine dependence. Conclusion. The intervention suggests the effect on habit acquisition was slight but not so on cessation. Preventive interventions should be carried out before students go to university, while more specific cessation programmes are required to reduce tobacco use among students. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper was to describe the use of dental services and the prevalence of dental caries in children living in Madrid, Spain. Methods: A descriptive, cross-sectional study was conducted using data from the Madrid City Health Survey. The questions asked were: (1) When was the last time your child visited the dentist? (2) What was the reason for your child's last visit? and (3) Is your child currently suffering from caries, fillings, or bleeding from the gums when brushing? The independent variables included: sex; age; education level; and nationality. Results: Data from 960 children (approximately 27% of whom were immigrants) were analyzed. Over the last year, approximately 59% of the children had received dental care and 28% suffered from caries. After multivariate analysis, we observed that 3- to 6-year-old children, immigrants, and children of parents with low education levels are more likely not to have received dental care during the last year. We also found that children are more likely to suffer from caries as they get older and if they are immigrants. Conclusions: Being an immigrant and from a lower education level typically results in a less frequent use of dental health services, and children of immigrants have a greater risk of suffering from dental caries. It is essential to investigate the reasons why and introduce strategies to reduce barriers to dental health access among immigrants. [ABSTRACT FROM AUTHOR]

Abstract: In this paper, we briefly review theories and findings on migration and health from the health equity perspective, and then analyse migration-related health inequalities taking into account gender, social class and migration characteristics in the adult population aged 25–64 living in Catalonia, Spain. On the basis of the characterisation of migration types derived from the review, we distinguished between immigrants from other regions of Spain and those from other countries, and within each group, those from richer or poorer areas; foreign immigrants from low-income countries were also distinguished according to duration of residence. Further stratification by sex and social class was applied. Groups were compared in relation to self-assessed health in two cross-sectional population-based surveys, and in relation to indicators of socio-economic conditions (individual income, an index of material and financial assets, and an index of employment precariousness) in one survey. Social class and gender inequalities were evident in both health and socio-economic conditions, and within both the native and immigrant subgroups. Migration-related health inequalities affected both internal and international immigrants, but were mainly limited to those from poor areas, were generally consistent with their socio-economic deprivation, and apparently more pronounced in manual social classes and especially for women. Foreign immigrants from poor countries had the poorest socio-economic situation but relatively better health (especially men with shorter length of residence). Our findings on immigrants from Spain highlight the transitory nature of the ‘healthy immigrant effect’, and that action on inequality in socio-economic determinants affecting migrant groups should not be deferred. [Copyright &y& Elsevier]

Purpose: Only 53% and 63% of studies and clinical trials results presented at congresses are published. Company-sponsored trial results are being posted on publicly accessible Web sites. We analyzed the public availability (publication or posting on a Web site) rate, time to publication, and factors predicting public availability of results of studies sponsored by a pharmaceutical company. Methods: This was a retrospective cohort study analyzing all studies conducted by GlaxoSmithKline in Spain between 2001 and 2006. Initiation and completion were defined as first participant/first visit and last participant/last visit (or their equivalents). Papers published up to 31 March 2009 were considered. Logistic regression models were used to identify factors predicting public availability of results. Results: The cohort comprised 143 studies (94 clinical trials; of these, 87 were included in international products clinical development plans). Public availability rate was 80% (114/143) for all studies and 78% (73/94) for clinical trials; publication rates were 68% and 61%, respectively. The median time to publication for all studies and trials was 27.3 and 28.4 months, respectively. Study associated to a cancelled project was the only significant factor associated with lower publication rate for all studies [odds ratio (OR) 0.069; 95% confidence interval (CI) 0.02-024; p < 0.001) and trials (OR 0.075; 95% CI 0.016-0.343; p = 0.001) and a lower public availability rate (OR 0.052; 95% CI 0.007-0.382; p = 0.004) for trial results. Therapy area, sample size, positive trial results, duration of experimental phase, and being a clinical trial did not predict publication or public availability. Conclusions: Eighty percent of studies included in this analysis are publicly available. Web site posting increases public availability rate of clinical trial results from 61% to 78%. Cancellation of projects is the single factor negatively influencing publication and public availability rates. [ABSTRACT FROM AUTHOR]

Gypsy population constitutes the most important ethnic minority in Spain (more than 2% of population). Our country has the third largest gypsy population in the world. Although their presence among us dates from more than 600 years ago and their culture and their health needs are very different from ours, lack of interest about this group of population has been important. The growing migration process that has happened in our country during the last years has also produced an increasing concern about the health needs of gypsies. This paper aims to summarize the scarce present medical and anthropological knowledge on gypsies. The aim is to provide the health professionals with minimal skills to avoid possible prejudices towards this ethnic group and provide them high quality health care. [ABSTRACT FROM AUTHOR]

Previously published scientific papers have reported a negative correlation between drinking water hardness and cardiovascular mortality. Some ecologic and case-control studies suggest the protective effect of calcium and magnesium concentration in drinking water. In this article we present an analysis of this protective relationship in 538 municipalities of Comunidad Valenciana (Spain) from 1991-1998. We used the Spanish version of the Rapid Inquiry Facility (RIF) developed under the European Environment and Health Information System (EUROHEIS) research project. The strategy of analysis used in our study conforms to the exploratory nature of the RIF that is used as a tool to obtain quick and flexible insight into epidemiologic surveillance problems. This article describes the use of the RIF to explore possible associations between disease indicators and environmental factors. We used exposure analysis to assess the effect of both protective factors— calcium and magnesium—on mortality from cerebrovascular (ICD-9 430-438) and ischemic heart (ICD-9 410-414) diseases. This study provides statistical evidence of the relationship between mortality from cardiovascular diseases and hardness of drinking water. This relationship is stronger in cerebrovascular disease than in ischemic heart disease, is more pronounced for women than for men, and is more apparent with magnesium than with calcium concentration levels. Nevertheless, the protective nature of these two factors is not dearly established. Our results suggest the possibility of protectiveness but cannot be claimed as conclusive. The weak effects of these covariates make it difficult to separate them from the influence of socioeconomic and environmental factors. We have also performed disease mapping of standardized mortality ratios to detect clusters of municipalities with high risk. Further standardization by levels of calcium and magnesium in drinking water shows changes in the maps when we remove the effect of these covariates. [ABSTRACT FROM AUTHOR]