Zika virus disease in Spain. Surveillance results and epidemiology on reported cases, 2015–2017

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Since then&#44; the virus has spread rapidly and consistently&#44; peaking in the first quarter of 2016&#44; mainly in South America&#46; This generated an international alert&#44; culminating in February 2016 with the World Health Organisation&#39;s &#40;WHO&#41; declaration that the microcephaly associated with ZVD was a public health emergency of international importance&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> The number of cases decreased in the second quarter of that year&#44; when cases in the Caribbean region were more prominent&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> and continued to decrease during 2016 and 2017&#46; The disease can currently be found around the world&#44; mainly in tropical climates &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In Europe it is an imported disease&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">ZV is transmitted by the <span class="elsevierStyleItalic">Aedes</span> genus mosquito bite&#44; mainly <span class="elsevierStyleItalic">Aedes aegypti</span>&#44; although other species have been also been associated with its spread in certain epidemics&#46; In continental Europe&#44; the <span class="elsevierStyleItalic">Aedes albopictus</span> invasive mosquito is widely distributed throughout Mediterranean regions and continues to spread towards more northern climates&#59; its vector competence as a transmitter of ZV is under study&#44; but it is less efficient than <span class="elsevierStyleItalic">A&#46; aegypti&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5&#44;6</span></a> In Europe&#44; it has only been established in Madeira&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> although it was recently detected in Fuerteventura in an isolated event&#44; with low risk of introduction&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> In Spain <span class="elsevierStyleItalic">A&#46; albopictus</span>&#8217; vector competence is considered to run from May to October&#44; and until 2017 it is believed to have colonised seven regions in Spain &#40;Autonomous Regions &#91;AR&#93;&#41;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;10</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Other routes of transmission are sexual&#44; vertical and transfusions&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The differential diagnosis of ZVD is complex&#44; due to its epidemiological and clinical characteristics that are common with other diseases and the problems of cross-reactivity with other <span class="elsevierStyleItalic">Flaviviruses</span>&#44; which makes neutralisation tests essential&#46; The infection occurs asymptomatically in approximately 80&#37; of cases&#46; In the remaining 20&#37;&#44; symptoms are mild and self-limiting&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2&#44;3</span></a> In some cases&#44; the virus can produce Guillain-Barr&#233; syndrome&#44; and if transmitted vertically&#44; foetal or neonatal complications or malformations&#46; It is not known whether the disease generates long-term immunity&#44; and there are no vaccines or specific treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Surveillance of ZVD in Spain began in 2016&#46; Since then&#44; this disease and congenital infection have been monitored through the Epidemiological Surveillance National Network &#40;RENAVE&#41;&#44; which comprises Public Health representatives from all ARs&#44; the National Epidemiology Centre&#44; Ministry of Health&#44; Consumer and Social Affairs body and National Microbiology Centre as a reference laboratory&#46; Surveillance protocols were developed to notify cases&#44; which are updated according to emerging new evidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The objectives of this study is to explore the epidemiology of ZVD cases reported in Spain since the beginning of its surveillance&#44; and pregnancy results in the cases of infected pregnant women&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A descriptive study of all the cases of congenital disease or infection by ZV reported to RENAVE by AR was carried out&#46; Surveillance began on February 1&#44; 2016&#44; and all cases diagnosed since the beginning of the epidemic were collected&#46; On this basis&#44; the cases included were those whose symptoms onset dates were from 30&#47;11&#47;2015 &#40;week 49&#41; to 31&#47;12&#47;2017 &#40;week 52&#41;&#46; The symptoms onset date&#44; or the closest to it&#44; in cases when it was not known&#44; was the one used for the analysis &#40;key date&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Cases were registered in the computer surveillance platform used by RENAVE called by its acronym SiViEs&#44; managed by the Carlos III Health Institute National Epidemiology Centre&#59; this software complies with all the legal and technical requirements to ensure safe access and protection of its data&#46; In Spain&#44; no explicit authorisation is required from an Ethics Committee to carry out epidemiological surveillance and disseminate its results&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The definition of case was agreed upon in the protocols and was modified throughout according to WHO and the European Centre for Disease Prevention and Control &#40;ECDC&#41; requirements&#44; as well as any new evidence arising during that period&#46; Since May 2016&#44; a probable case of ZVD was defined as a patient who had presented a rash with or without fever and one other compatible symptom&#44; in addition to any of the following laboratory results&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Positive serology for IgM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Seroconversion of IgG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;c&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Increase of four times the antibody titre&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">A case was considered confirmed if&#44; regardless of symptoms&#44; the patient had one of the following results&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Detection of IgM antibodies and positive neutralisation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Nucleic acid detection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;c&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Isolation of the virus&#46;</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">A probable congenital infection was considered to be any foetus&#44; stillbirth or newborn with any of the compatible neurological clinical findings&#44; in addition to IgM or persistence of IgG in at least two samples until 12 months of age&#46; A congenital case was considered confirmed if nucleic acid was detected or the IgM serology was confirmed with neutralisation&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">When contagion took place in Spain&#44; the case was defined as autochthonous or non-imported&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The variables used were those of the RENAVE case study&#58; key date&#44; AR residence of the case&#44; case classification &#40;confirmed or probable&#41;&#44; mode and place the disease was caught &#40;imported&#44; country and form of contagion&#44; reason for travel&#41;&#44; sociodemographic data &#40;age&#44; sex&#44; country of birth and residence&#41;&#44; clinical data &#40;symptoms&#44; complications&#44; hospitalisation&#44; death&#41;&#44; laboratory diagnosis&#44; pregnancy and its evolution&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A descriptive analysis of the temporal and spatial distribution of the cases was carried out according to their classification by key date and AR&#44; as well as the other variables&#46; Notification rates &#40;cases per 100&#44;000 inhabitants&#41; and their 95&#37; confidence intervals &#40;95&#37; CI&#41; were calculated according to AR for 2016 and 2017&#46; The total number and percentages were calculated to describe qualitative variables and quantitative variables were described by centralisation and dispersion&#44; according to their adjustment to the normal distribution&#46; The software used to analyse the data was Stata version 14&#44; Excel 2013 and Epidat 4&#46;2&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">512 cases of ZVD were notified whose key dates ranged from week 49 of 2015 to week 52 of 2017&#46; Out of all the cases&#44; five were congenital&#44; and are described in a specific section&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Of the 507 non-congenital cases&#44; 354 &#40;69&#46;8&#37;&#41; were confirmed and 153 probable&#46; The main characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; 64&#46;5&#37; of the sample were female and the mean age was 34 &#40;P25&#8211;75&#58; 27&#8211;42&#59; range 1&#8211;82&#41;&#59; 266 cases &#40;52&#46;5&#37;&#41; occurred in females of childbearing age &#40;15&#8211;49 years&#41;&#46; Of those born outside of Spain &#40;152&#44; 30&#46;0&#37;&#41;&#44; 149 &#40;98&#46;0&#37;&#41; came from a country in Latin America&#46; The most frequent were Colombia &#40;45&#47;149&#44; 30&#46;2&#37;&#41; and the Dominican Republic &#40;31&#47;149&#44; 20&#46;8&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Fourteen cases &#40;2&#46;8&#37;&#41; corresponded to 2015&#44; 403 &#40;79&#46;5&#37;&#41; to 2016 and 90 &#40;17&#46;7&#37;&#41; to 2017 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The peak of declarations occurred at week 33 of 2016 &#40;21&#59; 4&#46;1&#37;&#41;&#44; subsequently descending until week 36&#44; when 0&#8211;6 cases were reported per week&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Non-congenital cases were distributed according to residence in 17 AR &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The largest number of cases occurred in Catalonia and Madrid&#59; 308 cases &#40;60&#46;7&#37;&#41; resided in an AR colonised by the vector and the date of 193 &#40;38&#46;1&#37;&#41; cases corresponded to the period of activity of <span class="elsevierStyleItalic">A&#46; albopictus</span>&#46; In 2015&#44; cases were reported from Catalonia &#40;11&#41;&#44; Galicia &#40;2&#41; and Madrid &#40;1&#41;&#46; The rates&#44; calculated for 2016 and 2017&#44; were higher in Catalonia&#44; La Rioja and Madrid &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">No case was declared by indigenous vector transmission&#46; Of the non-congenital cases&#44; two &#40;0&#46;4&#37;&#41; were not imported&#58; both were women who were infected by sexual transmission&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Of the 505 imported cases&#44; the possible geographic region of contagion was known for 490 &#40;97&#46;0&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Of these&#44; 471 &#40;96&#46;1&#37;&#41; originated in the Americas &#40;469 in Latin America&#41;&#44; 13 &#40;2&#46;6&#37;&#41; in Asia&#47;Pacific and 6 &#40;1&#46;2&#37;&#41; in Africa&#46; The most frequent countries of origin were the Dominican Republic &#40;108&#47;490&#44; 22&#46;0&#37;&#41; and Colombia &#40;64&#47;490&#44; 13&#46;1&#37;&#41;&#46; Disaggregated by year of notification&#44; in 2015&#8211;2016 cases from the Dominican Republic &#40;105&#47;402&#44; 26&#46;1&#37;&#41; and Colombia &#40;64&#47;402&#44; 15&#46;9&#37;&#41; predominated&#44; while in 2017 the highest number of cases were imported from Cuba &#40;36&#47;82&#44; 43&#46;9&#37;&#41; and Ecuador &#40;15&#47;82&#44; 18&#46;3&#37;&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The reason for the trip was reported in 303 cases &#40;60&#46;0&#37;&#41;&#59; the most frequent was to visit relatives or friends &#40;VRF&#41;&#44; 163 &#40;53&#46;8&#37;&#41; cases&#44; followed by tourism&#44; 80 &#40;26&#46;4&#37;&#41; cases&#46; A higher frequency of VRF was observed in those who contracted the infection in South American countries&#44; while travel by tourism was more frequent in those who were infected in Central America and the Caribbean &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">The majority of confirmed cases &#40;286&#47;349&#44; 81&#46;9&#37;&#41; were diagnosed by genome detection in serum or urine&#46; In 13 cases there was coinfection due to dengue or chikungunya virus&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Excluding cases of congenital infection by ZV&#44; information on clinical data was available in 268 cases &#40;52&#46;9&#37;&#41;&#46; The most frequent symptoms were rash &#40;86&#46;0&#37;&#41; and fever &#40;69&#46;1&#37;&#41;&#46; In two cases&#44; non-obstetric neurological complications were reported&#58; one case was compatible with Guillain-Barr&#233; and another with polyneuropathy&#46; Hospitalisation occurred in 33 cases &#40;6&#46;5&#37;&#44; 95&#37; CI&#58; &#40;4&#46;5&#8211;9&#46;0&#41;&#41;&#46; No death was reported&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Infection in pregnant women and neonatal cases</span><p id="par0150" class="elsevierStylePara elsevierViewall">A total of 86 females aged 16&#8211;42 years &#40;median 29 years&#41; were pregnant at the time of sampling&#46; One female patient had been infected through intercourse&#46; The most frequent contagion countries were the Dominican Republic &#40;30&#44; 34&#46;9&#37;&#41; and Honduras &#40;14&#44; 16&#46;3&#37;&#41;&#46; Of the 75 women with known data&#44; 20 &#40;26&#46;7&#37;&#41; were in the first trimester of pregnancy&#44; 42 &#40;56&#46;0&#37;&#41; in the second and 13 &#40;17&#46;3&#37;&#41; in the third&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Information of the pregnancy duration was available in 85 of the 86 women&#46; Pregnancy was completed in 75 cases &#40;88&#46;2&#37;&#44; 95&#37; CI&#58; 79&#46;4&#8211;94&#46;2&#41;&#59; of them&#58; 74 gave birth to uninfected newborns and one was born with microcephaly and was diagnosed with confirmed congenital Zika&#59; six females &#40;7&#46;1&#37;&#59; 95&#37; CI&#58; 2&#46;6&#8211;14&#46;7&#41; underwent voluntary interruptions of pregnancy&#59; two of those foetuses were diagnosed with congenital Zika confirmed by laboratory and there was no microbiological information available for the other four&#46; Finally&#44; four of the 85 women &#40;4&#46;7&#37;&#44; 95&#37; CI&#58; 1&#46;3&#8211;11&#46;6&#41; had spontaneous abortions&#59; there is no available information on those embryos or foetuses&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The proportion of pregnancies with confirmed congenital Zika&#44; in those with information regarding the neonate&#44; foetus or embryo was 3&#46;9&#37; &#40;3&#47;77&#41;&#44; 95&#37; CI&#58; 0&#46;8&#8211;11&#46;0&#46; Three women were exposed during their first trimester of pregnancy&#44; one did not present symptoms of illness and was diagnosed during a routine control of her pregnancy&#44; and another was aged over 40 and co-infected with dengue virus&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In addition&#44; two other congenital cases were reported to have been born to newly arrived immigrant women whose disease was not diagnosed in Spain&#44; such that they were not included in this analysis&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0170" class="elsevierStylePara elsevierViewall">ZVD surveillance began in Spain in 2016&#44; and cases were reported from week 49 of 2015&#46; 79&#46;5&#37; of the cases corresponded to 2016&#44; peaking in week 33 and subsequently decreasing&#46; 64&#46;5&#37; of patients were female and the median age was 34&#46; The majority of the cases resided in Spain and&#44; although we did not know the place of birth and the reason for the trip in a high percentage&#44; around 30&#37; of the cases were of Latin American origin and travelled to VRF&#46; In 96&#37; of the cases infection occurred in Latin America&#46; Cases occurred most frequently in Catalonia and Madrid&#44; which also had the highest rates&#44; along with La Rioja&#46; The presentation of the cases was benign and their evolution was favourable&#44; with less than 10&#37; of hospitalisations&#46; One case of Guillain-Barr&#233; syndrome and three cases &#40;3&#46;9&#37;&#41; of congenital infection were detected in pregnant women&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The temporal distribution of the cases reported to RENAVE was consistent with the evolution of the disease rates in the Americas region<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;13</span></a> and with that described by other studies on imported cases of ZVD and other diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">14&#44;15</span></a> It is important to note the close historical and cultural relationship between Spain and Latin America&#46; According to the Statistical Institute of Spain&#44; in 2017 2&#44;419&#44;842 people born in Latin American countries &#40;nationalised or not&#41; lived in Spain&#44; with a femininity index of 135&#46; These people make and receive frequent visits to their places of origin&#46; In addition&#44; Latin America is a common tourist destination for Spaniards&#46; The number of travellers from the Americas &#40;not including North America&#41; in 2016 and 2017 was 2&#44;572&#44;071 and 3&#44;236&#44;407&#44; respectively&#46; Spain received 105&#44;866 immigrants born in Latin America in 2015 out of a total of 342&#44;114&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Catalonia and Madrid&#44; both with high numbers of international travellers and a large number of non-Spanish residents concentrated in large cities&#44; had the highest number of notifications&#46; In regard to Catalonia&#44; it is worth noting that its greater sensitivity in the detection of cases is probably due to the fact that it was the first region to identify <span class="elsevierStyleItalic">A&#46; albopictus</span> and in implementing an arbovirosis surveillance and control programme&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">A total of 267 of the 328 women were of childbearing age &#40;81&#46;4&#37; vs&#46; 44&#46;8&#37; in the general population in 2017&#41; and 86 &#40;26&#46;2&#37;&#41; were pregnant&#46; The overrepresentation of women and the high proportion of pregnant women is also observed in other case studies of ZVD&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#8211;21</span></a> This could be explained by the fact that this population group more often requests diagnostic tests given the risk of foetal malformations&#44; and that there are more Latin America women residents in Spain than men&#46; Another possible explanation could be that women presented a higher risk of disease&#44; although a seroprevalence study conducted into an outbreak on Yap Island found that risk of infection was higher in men&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">A high proportion of ZVD cases contracted the infection during VRF&#46; This group of people plan less for trips&#44; stay longer and travel to more insecure areas&#44; so are thus more likely to suffer from mosquito bites&#44; such that the risk of getting sick exceeds that of other tourists&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Previous studies reveal that those travelling to VRF ask fewer questions about the location they are travelling to&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> In addition&#44; according to studies conducted in the United States and Europe&#44; their primary source of health information for these travellers are primary care doctors&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">24&#44;25</span></a> In Spain&#44; the health services most used by immigrants are the primary care and emergency departments&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> All this reinforces the need to establish or support strategies aimed at this risk group&#44; from general medicine and emergency departments&#44; and all other health units&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The frequency of symptoms&#44; rash in 86&#46;0&#37; and fever in 69&#46;1&#37; of known clinical cases&#44; is largely due to the fact that they are part of the clinical criteria that defines a case&#46; The frequency of hospitalisation &#40;6&#46;5&#37;&#44; 4&#46;5&#8211;9&#46;0&#41; was higher than that of a study in Colombia &#40;4&#37;&#41; and similar to that of France &#40;5&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The proportion of foetal alterations associated with Zika infection during pregnancy &#40;3&#46;9&#37;&#44; 95&#37; CI&#58; 0&#46;8&#8211;11&#46;0&#41; was lower than that found in pregnant women in the United States &#40;4&#8211;6&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> although our estimate was imprecise due to a smaller sample size&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Surveillance of ZVD began shortly after the alert was generated&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> so there could be differences between each AR notification capacity after detection&#46; In addition&#44; certain variables presented high percentages of lost data&#46; Furthermore&#44; the inclusion of probable cases could overestimate the number of cases&#46; Finally&#44; due to the absence of an adequate denominator of the population at risk of contracting ZVD&#44; the resident population could only be adjusted by AR&#46; However&#44; we consider that the participation of all AR in the creation of the protocols favoured the extensive and uniformity of the notification process throughout the territory&#46; All regions except Cantabria reported cases in the first year&#44; and only Ceuta and Melilla did not detect any cases&#44; so the establishment of the process seems to have been homogeneous&#46; The absence of diagnostic tools most probably did not limit the process&#44; as the National Centre of Microbiology was available from the beginning&#46; Missing data offer an opportunity for improvement for a more accurate description of the ZVD epidemiology in our context&#44; and it was not a limitation for this study&#44; as no association between the variables was explored&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">RENAVE is the only source of ZVD cases in all areas &#40;including outpatient&#41; and has national reach&#46; Although under-reporting is assumed&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> reported cases in general would be representative of those diagnosed in our setting&#46; Our results could be partially extrapolated to other regions with similar characteristics&#44; except in aspects such as the origin of cases &#8211; whose pattern depends on the relationships with countries with indigenous transmission &#8211; and for certain estimates which were not precise&#44; making their comparison difficult&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Since 2007&#44; outbreaks of dengue fever and chikungunya fever transmitted locally by <span class="elsevierStyleItalic">A&#46; albopictus</span> have occurred in Europe&#44; the latests have been in Spain and France&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> No case of autochthonous vectorial transmission of ZV has been described in Spain or in our context and the risk of its occurrence is considered very low&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">21&#44;28</span></a> However&#44; due to the presence of a vector&#44; a susceptible population &#8211; considering pregnant women to be a group that is of special risk &#8211; and a considerable number of people in the viremic phase in places and during periods of activity of <span class="elsevierStyleItalic">A&#46; albopictus</span> in Spain&#44; surveillance is essential&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;28</span></a> Additionally&#44; entomological surveillance allows us to identify new areas colonised by mosquitoes and to deepen our knowledge on their transmissibility potential&#46; Finally&#44; the surveillance of imported diseases has proven to be useful as global sentinel surveillance&#44; especially in the case of diseases that circulate in places where circumstances do not favour their detection&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">14&#44;15</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Conflict of interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2018-08-09"
    "fechaAceptado" => "2018-12-13"
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            0 => "Zika virus"
            1 => "Surveillance"
            2 => "Spain"
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            0 => "Virus Zika"
            1 => "Vigilancia"
            2 => "Espa&#241;a"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Zika virus disease is a challenge for public health due to its rapid spread and potential foetal complications&#46; Although it is imported in Spain&#44; there is a risk of autochthonous transmission due to <span class="elsevierStyleItalic">Aedes albopictus</span> presence&#46; Zika disease and congenital cases have been under surveillance since 2016&#46; The objective of this study is to explore the epidemiology of disease and pregnancies result&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A descriptive study was carried out into cases reported to the National Surveillance Network &#40;RENAVE&#41; during the 30&#47;11&#47;2015 to 31&#47;12&#47;2017 period&#46; The case definition and the survey are included in the RENAVE protocol&#46; The variables were&#58; date&#59; notifying region &#40;Autonomous Community &#40;AC&#41;&#41;&#59; pregnancy and its evolution&#59; case classification&#59; mode of transmission&#59; country or region of infection&#59; socio-demographical&#44; clinical and microbiological data&#46; A descriptive analysis of the cases and their distribution according to the other variables was carried out&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 512 cases were reported by 17 ACs&#46; 507 were non-congenital&#44; of which 327 &#40;64&#46;5&#37;&#41; were women &#40;52&#46;5&#37; of childbearing age&#41;&#46; 403 cases &#40;79&#46;5&#37;&#41; corresponded to 2016 and 193 &#40;38&#46;1&#37;&#41; resided in regions with <span class="elsevierStyleItalic">A&#46; albopictus</span> presence between May and October&#46; 96&#46;1&#37; of imported cases were infected in America &#40;51&#46;7&#37; while visiting relatives&#41;&#46; Three cases &#40;3&#46;9&#37;&#41; of congenital Zika virus infection were detected among 77 pregnant women&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The evolution of reported cases was in accordance with that of the epidemic in America&#46; The largest group of travellers was young women who travelled to Latin America on family visits&#46; Pregnancy monitoring resulted in the identification of Zika related foetal complications&#46;</p></span>"
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            "titulo" => "Introduction and objective"
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            "titulo" => "Results"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La enfermedad por virus Zika constituye un reto para la salud p&#250;blica por su r&#225;pida expansi&#243;n y sus potenciales complicaciones fetales&#46; En Espa&#241;a la enfermedad por virus Zika es importada&#44; aunque la presencia de <span class="elsevierStyleItalic">Aedes albopictus</span> no descarta su transmisi&#243;n aut&#243;ctona&#46; La enfermedad por virus Zika y los casos cong&#233;nitos se vigilan desde 2016&#46; El objetivo es conocer su epidemiolog&#237;a y el resultado de la gestaci&#243;n en las embarazadas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo de casos notificados a la Red Nacional de Vigilancia Epidemiol&#243;gica &#40;RENAVE&#41; entre el 30&#47;11&#47;2015 y el 31&#47;12&#47;2017&#46; La definici&#243;n de caso y la encuesta se recogen en los protocolos de la RENAVE&#46; Las variables fueron&#58; fecha&#44; comunidad aut&#243;noma &#40;CC&#46;AA&#46;&#41;&#44; clasificaci&#243;n&#44; modo y lugar de infecci&#243;n&#44; variables sociodemogr&#225;ficas&#44; cl&#237;nicas&#44; microbiol&#243;gicas&#44; embarazo y su evoluci&#243;n&#46; Se realiz&#243; un an&#225;lisis descriptivo de los casos y su distribuci&#243;n seg&#250;n el resto de variables&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Diecisiete CC&#46;AA&#46; notificaron 512 casos&#44; de los cuales 507 fueron no cong&#233;nitos&#58; 327 &#40;64&#44;5&#37;&#41; eran mujeres &#40;52&#44;5&#37; en edad f&#233;rtil&#41;&#59; 403 casos &#40;79&#44;5&#37;&#41; correspondieron a 2016 y 193 &#40;38&#44;1&#37;&#41; resid&#237;an en CC&#46;AA&#46; colonizadas por <span class="elsevierStyleItalic">A&#46; albopictus</span> entre mayo y octubre&#46; El 96&#44;1&#37; de casos importados se infectaron en Am&#233;rica y el 51&#44;7&#37; en visitas familiares&#46; Se detectaron 3 casos de infecci&#243;n cong&#233;nita en 77 embarazadas&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La evoluci&#243;n de notificaciones mostr&#243; paralelismo con la de la epidemia en Am&#233;rica&#46; El grupo m&#225;s numeroso de viajeros fue el de mujeres j&#243;venes que fueron a Latinoam&#233;rica en visitas familiares&#46; El seguimiento de las embarazadas permiti&#243; identificar complicaciones fetales&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">The names of the components of the RENAVE group are related in <a class="elsevierStyleCrossRef" href="#sec0035">Annex</a>&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Fern&#225;ndez Mart&#237;nez B&#44; Mart&#237;nez S&#225;nchez EV&#44; D&#237;az Garc&#237;a O&#44; G&#243;mez Barroso D&#44; Sierra Moros MJ&#44; Cano Portero R&#44; et al&#46; La enfermedad por virus Zika en Espa&#241;a&#46; Resultados de la vigilancia y epidemiolog&#237;a de los casos notificados en 2015-2017&#46; Med Clin &#40;Barc&#41;&#46; 2019&#59;153&#58;6&#8211;12&#46;</p>"
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            "apendice" => "<p id="par0225" class="elsevierStylePara elsevierViewall">Andalusia&#58; Mercedes P&#233;rez Ruiz &#40;Virgen de las Nieves University Hospital&#44; Microbiology Service&#41;&#59; Enric Dur&#225;n Pl&#225; &#40;Regional Ministry for Health&#44; Surveillance and Labour Health Service&#41;&#46;</p> <p id="par0230" class="elsevierStylePara elsevierViewall">Aragon&#58; Ana Delia Cebollada Gracia and Alberto Vergara Ugarriza &#40;General Directorate of Public Health&#41;&#46;</p> <p id="par0235" class="elsevierStylePara elsevierViewall">Asturias&#58; Ismael Huerta Gonz&#225;lez &#40;Epidemiological Surveillance Service&#44; General Directorate of Public Health&#41;&#46;</p> <p id="par0240" class="elsevierStylePara elsevierViewall">Balearic Islands&#58; Paula Grau Sancho and Isabel Cataliba Bosch &#40;Epidemiology Service&#44; General Directorate of Public Health and Participation&#41;&#46;</p> <p id="par0245" class="elsevierStylePara elsevierViewall">Canary Islands&#58; Magdalena L&#46; Rojo Moreno and Alicia Pla Franc&#233;s &#40;General Directorate of Public Health&#41;&#46;</p> <p id="par0250" class="elsevierStylePara elsevierViewall">Cantabria&#58; Aniceto Blasco de la Fuente and Luis Javier Viloria Raymundo &#40;Regional Ministry of Health&#44; Epidemiological Surveillance Section&#41;&#46;</p> <p id="par0255" class="elsevierStylePara elsevierViewall">Castile and Le&#243;n&#58; Cristina Ruiz Sope&#241;a and Socorro Fern&#225;ndez Arribas &#40;Regional Ministry of Health&#44; Epidemiology Service&#44; General Directorate of Public Health&#41;&#46;</p> <p id="par0260" class="elsevierStylePara elsevierViewall">Castilla-La Mancha&#58; Pilar Peces Jimenez &#40;General Directorate of Public Health&#44; Health Information and Epidemiological Surveillance Service&#41;&#46;</p> <p id="par0265" class="elsevierStylePara elsevierViewall">Catalonia&#58; N&#250;ria Torner Gr&#224;cia and Mireia Jan&#233; Checa &#40;Public Health&#44; Epidemiological Control&#44; Surveillance and Emergency Response Services&#41;&#46; Coordination Centre for Health Alerts and Emergencies&#58; Berta Su&#225;rez Rodr&#237;guez&#46;</p> <p id="par0270" class="elsevierStylePara elsevierViewall">Berta Su&#225;rez Rodr&#237;guez &#40;Coordination Centre for Health Alerts and Emergencies&#46; Ministry of Health&#44; Consumption and Social Welfare&#41;&#46;</p> <p id="par0275" class="elsevierStylePara elsevierViewall">Mar&#237;a Paz S&#225;nchez-Seco Fari&#241;a &#40;National Centre of Microbiology&#44; Carlos III Health Institute&#41;&#46;</p> <p id="par0280" class="elsevierStylePara elsevierViewall">Ceuta&#58; Ana I&#46; Rivas P&#233;rez &#40;Regional Ministry of Health&#44; Epidemiological Surveillance Service&#41;&#46;</p> <p id="par0285" class="elsevierStylePara elsevierViewall">Extremadura&#58; Juli&#225;n Mauro Ramos Aceitero &#40;General Directorate of Public Health&#44; Subdirectorate of Epidemiology&#41;&#46;</p> <p id="par0290" class="elsevierStylePara elsevierViewall">Galicia&#58; &#193;nxela Pousa Ortega and Mar&#237;a Jes&#250;s Purri&#241;os Hermida &#40;General Directorate of Public Health&#44; Epidemiology Services&#41;&#46;</p> <p id="par0295" class="elsevierStylePara elsevierViewall">Madrid&#58; Alba Nieto Juli&#225; and Pello Latasa Zamalloa &#40;General Directorate of Public Health&#44; Epidemiology Service&#41;&#46;</p> <p id="par0300" class="elsevierStylePara elsevierViewall">Melilla&#58; Daniel Castrillejo P&#233;rez &#40;Regional Ministry of Public Health&#44; Epidemiology Service&#41;&#46;</p> <p id="par0305" class="elsevierStylePara elsevierViewall">Murcia&#58; Visitaci&#243;n Garcia Ort&#250;zar &#40;General Directorate of Public Health&#44; Epidemiological Surveillance&#41;&#46;</p> <p id="par0310" class="elsevierStylePara elsevierViewall">Navarra Itziar Casado and Jes&#250;s Castilla &#40;Navarra Institute of Public Health&#44; CIBERESP&#41;&#46;</p> <p id="par0315" class="elsevierStylePara elsevierViewall">Basque Country&#58; Fernando Gonz&#225;lez-Carril and Jose Mar&#237;a Artegoitia Axpe &#40;Directorate of Public Health and Addictions&#44; Epidemiological Surveillance Service and Vaccines&#41;&#46;</p> <p id="par0320" class="elsevierStylePara elsevierViewall">La Rioja&#58; Eva Mart&#237;nez Ochoa and Ana Carmen Ib&#225;&#241;ez P&#233;rez &#40;General Directorate of Public Health and Consumption&#44; Epidemiology and Health Prevention Service&#41;&#46;</p> <p id="par0325" class="elsevierStylePara elsevierViewall">Valencian Community&#58; Isabel Huertas Zarco and Katja Villatoro Bongiorno &#40;Regional Ministry of Health&#44; Sub-Directorate General of Epidemiology and Health Surveillance&#41;&#46;</p>"
            "etiqueta" => "Annex"
            "titulo" => "RENAVE group components &#40;listed alphabetically by AR or body&#41;"
            "identificador" => "sec0035"
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                  \t\t\t\t">59 &#40;11&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;7&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;2&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Country of residence</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">490 &#40;96&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;2&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Place of birth</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">America&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">149 &#40;29&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">115 &#40;22&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other &#40;Europe&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">240 &#40;47&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reason for travel<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VRF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">163 &#40;32&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tourism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#40;15&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immigrant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Report&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">202 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Place of infection<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">South America&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">175 &#40;34&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Caribbean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">171 &#40;33&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central America&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">123 &#40;24&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Others<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;3&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Asia &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&#44; Africa &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&#44; United States &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Main characteristics of Zika virus disease cases &#40;excludes congenital cases&#41;&#46; Spain&#44; 2015&#8211;2017&#46;</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Rate &#40;95&#37; CI&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AR colonised by <span class="elsevierStyleItalic">Aedes albopictus</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Andalusia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;5&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;21 &#40;0&#46;13&#8211;0&#46;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;03 &#40;0&#46;01&#8211;0&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aragon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;98 &#40;0&#46;61&#8211;1&#46;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;04 &#40;0&#46;00&#8211;0&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Balearic Islands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;58 &#40;0&#46;23&#8211;1&#46;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;07 &#40;0&#46;00&#8211;0&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Catalonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">143 &#40;35&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53 &#40;58&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;92 &#40;1&#46;62&#8211;2&#46;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;71 &#40;0&#46;53&#8211;0&#46;93&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Valencian C&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;3&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;30 &#40;0&#46;17&#8211;0&#46;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;06 &#40;0&#46;01&#8211;0&#46;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Murcia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;21 &#40;0&#46;03&#8211;0&#46;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;10 &#40;0&#46;00&#8211;0&#46;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Basque Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;6&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;38 &#40;0&#46;88&#8211;2&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;17 &#40;0&#46;03&#8211;0&#46;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="10" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AR not colonised by <span class="elsevierStyleItalic">A&#46; albopictus</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asturias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;2&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;70 &#40;0&#46;34&#8211;1&#46;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Canary Islands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;2&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;44 &#40;0&#46;19&#8211;0&#46;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;11 &#40;0&#46;01&#8211;0&#46;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cantabria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;10 &#40;0&#46;00&#8211;0&#46;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Castilla y Le&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;44 &#40;0&#46;25&#8211;0&#46;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Castilla-La Mancha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;34 &#40;0&#46;13&#8211;0&#46;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extremadura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;18 &#40;0&#46;02&#8211;0&#46;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;09 &#40;0&#46;00&#8211;0&#46;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Galicia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;3&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;39 &#40;0&#46;20&#8211;0&#46;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;06 &#40;0&#46;01&#8211;0&#46;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Madrid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103 &#40;25&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;18&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                            4 => "J&#46; Cramer"
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