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

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Resultados de la vigilancia y epidemiología de los casos notificados en 2015-2017" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1625 "Ancho" => 2547 "Tamanyo" => 193072 ] ] "descripcion" => array:1 [ "en" => "Autonomous Regions (AR) colonised by Aedes albopictus (in at least one municipality) according to year and distribution of reported Zika virus disease (ZVD) cases according to AR. Spain, 2015–2017." ] ] ] "textoCompleto" => "IntroductionZika virus disease (ZVD) is considered one of the main emerging pathologies of the 20th century and a serious challenge for public health in the world.Zika virus (ZV) was first isolated in Uganda in 1947 in a rhesus macaque and soon after in humans, but the first major epidemic was not documented until 2007, on the island of Yap, followed by others in different locations in the Pacific in 2013 and 2014. Until then, it was not considered a relevant human pathogen. It is now known that the virus circulated in humans since its discovery in Africa and Asia.<a class="elsevierStyleCrossRefs" href="#bib0155">1–3</a> ZV was immediately associated with the Brazilian epidemic in 2015 and suspected to be related to the increase in cases of microcephaly. Since then, the virus has spread rapidly and consistently, peaking in the first quarter of 2016, mainly in South America. This generated an international alert, culminating in February 2016 with the World Health Organisation's (WHO) declaration that the microcephaly associated with ZVD was a public health emergency of international importance.<a class="elsevierStyleCrossRef" href="#bib0155">1</a> The number of cases decreased in the second quarter of that year, when cases in the Caribbean region were more prominent,<a class="elsevierStyleCrossRef" href="#bib0170">4</a> and continued to decrease during 2016 and 2017. The disease can currently be found around the world, mainly in tropical climates (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In Europe it is an imported disease.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>ZV is transmitted by the Aedes genus mosquito bite, mainly Aedes aegypti, although other species have been also been associated with its spread in certain epidemics. In continental Europe, the Aedes albopictus invasive mosquito is widely distributed throughout Mediterranean regions and continues to spread towards more northern climates; its vector competence as a transmitter of ZV is under study, but it is less efficient than A. aegypti.<a class="elsevierStyleCrossRefs" href="#bib0175">5,6</a> In Europe, it has only been established in Madeira,<a class="elsevierStyleCrossRef" href="#bib0185">7</a> although it was recently detected in Fuerteventura in an isolated event, with low risk of introduction.<a class="elsevierStyleCrossRef" href="#bib0190">8</a> In Spain A. albopictus’ vector competence is considered to run from May to October, and until 2017 it is believed to have colonised seven regions in Spain (Autonomous Regions [AR])<a class="elsevierStyleCrossRefs" href="#bib0195">9,10</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Other routes of transmission are sexual, vertical and transfusions.<a class="elsevierStyleCrossRef" href="#bib0160">2</a><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The differential diagnosis of ZVD is complex, due to its epidemiological and clinical characteristics that are common with other diseases and the problems of cross-reactivity with other Flaviviruses, which makes neutralisation tests essential. The infection occurs asymptomatically in approximately 80% of cases. In the remaining 20%, symptoms are mild and self-limiting.<a class="elsevierStyleCrossRefs" href="#bib0160">2,3</a> In some cases, the virus can produce Guillain-Barré syndrome, and if transmitted vertically, foetal or neonatal complications or malformations. It is not known whether the disease generates long-term immunity, and there are no vaccines or specific treatments.<a class="elsevierStyleCrossRef" href="#bib0160">2</a>Surveillance of ZVD in Spain began in 2016. Since then, this disease and congenital infection have been monitored through the Epidemiological Surveillance National Network (RENAVE), which comprises Public Health representatives from all ARs, the National Epidemiology Centre, Ministry of Health, Consumer and Social Affairs body and National Microbiology Centre as a reference laboratory. Surveillance protocols were developed to notify cases, which are updated according to emerging new evidence.<a class="elsevierStyleCrossRefs" href="#bib0205">11,12</a>The objectives of this study is to explore the epidemiology of ZVD cases reported in Spain since the beginning of its surveillance, and pregnancy results in the cases of infected pregnant women.MethodsA descriptive study of all the cases of congenital disease or infection by ZV reported to RENAVE by AR was carried out. Surveillance began on February 1, 2016, and all cases diagnosed since the beginning of the epidemic were collected. On this basis, the cases included were those whose symptoms onset dates were from 30/11/2015 (week 49) to 31/12/2017 (week 52). The symptoms onset date, or the closest to it, in cases when it was not known, was the one used for the analysis (key date).Cases were registered in the computer surveillance platform used by RENAVE called by its acronym SiViEs, managed by the Carlos III Health Institute National Epidemiology Centre; this software complies with all the legal and technical requirements to ensure safe access and protection of its data. In Spain, no explicit authorisation is required from an Ethics Committee to carry out epidemiological surveillance and disseminate its results.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 (ECDC) requirements, as well as any new evidence arising during that period. Since May 2016, a probable case of ZVD was defined as a patient who had presented a rash with or without fever and one other compatible symptom, in addition to any of the following laboratory results:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">(a)Positive serology for IgM.</li><li class="elsevierStyleListItem" id="lsti0010">(b)Seroconversion of IgG.</li><li class="elsevierStyleListItem" id="lsti0015">(c)Increase of four times the antibody titre.</li></ul>A case was considered confirmed if, regardless of symptoms, the patient had one of the following results:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">(a)Detection of IgM antibodies and positive neutralisation.</li><li class="elsevierStyleListItem" id="lsti0025">(b)Nucleic acid detection.</li><li class="elsevierStyleListItem" id="lsti0030">(c)Isolation of the virus.</li></ul>A probable congenital infection was considered to be any foetus, stillbirth or newborn with any of the compatible neurological clinical findings, in addition to IgM or persistence of IgG in at least two samples until 12 months of age. A congenital case was considered confirmed if nucleic acid was detected or the IgM serology was confirmed with neutralisation.<a class="elsevierStyleCrossRefs" href="#bib0205">11,12</a>When contagion took place in Spain, the case was defined as autochthonous or non-imported.The variables used were those of the RENAVE case study: key date, AR residence of the case, case classification (confirmed or probable), mode and place the disease was caught (imported, country and form of contagion, reason for travel), sociodemographic data (age, sex, country of birth and residence), clinical data (symptoms, complications, hospitalisation, death), laboratory diagnosis, pregnancy and its evolution.A descriptive analysis of the temporal and spatial distribution of the cases was carried out according to their classification by key date and AR, as well as the other variables. Notification rates (cases per 100,000 inhabitants) and their 95% confidence intervals (95% CI) were calculated according to AR for 2016 and 2017. The total number and percentages were calculated to describe qualitative variables and quantitative variables were described by centralisation and dispersion, according to their adjustment to the normal distribution. The software used to analyse the data was Stata version 14, Excel 2013 and Epidat 4.2.Results512 cases of ZVD were notified whose key dates ranged from week 49 of 2015 to week 52 of 2017. Out of all the cases, five were congenital, and are described in a specific section.Of the 507 non-congenital cases, 354 (69.8%) were confirmed and 153 probable. The main characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. 64.5% of the sample were female and the mean age was 34 (P25–75: 27–42; range 1–82); 266 cases (52.5%) occurred in females of childbearing age (15–49 years). Of those born outside of Spain (152, 30.0%), 149 (98.0%) came from a country in Latin America. The most frequent were Colombia (45/149, 30.2%) and the Dominican Republic (31/149, 20.8%).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Fourteen cases (2.8%) corresponded to 2015, 403 (79.5%) to 2016 and 90 (17.7%) to 2017 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The peak of declarations occurred at week 33 of 2016 (21; 4.1%), subsequently descending until week 36, when 0–6 cases were reported per week.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Non-congenital cases were distributed according to residence in 17 AR (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The largest number of cases occurred in Catalonia and Madrid; 308 cases (60.7%) resided in an AR colonised by the vector and the date of 193 (38.1%) cases corresponded to the period of activity of A. albopictus. In 2015, cases were reported from Catalonia (11), Galicia (2) and Madrid (1). The rates, calculated for 2016 and 2017, were higher in Catalonia, La Rioja and Madrid (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>No case was declared by indigenous vector transmission. Of the non-congenital cases, two (0.4%) were not imported: both were women who were infected by sexual transmission.Of the 505 imported cases, the possible geographic region of contagion was known for 490 (97.0%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Of these, 471 (96.1%) originated in the Americas (469 in Latin America), 13 (2.6%) in Asia/Pacific and 6 (1.2%) in Africa. The most frequent countries of origin were the Dominican Republic (108/490, 22.0%) and Colombia (64/490, 13.1%). Disaggregated by year of notification, in 2015–2016 cases from the Dominican Republic (105/402, 26.1%) and Colombia (64/402, 15.9%) predominated, while in 2017 the highest number of cases were imported from Cuba (36/82, 43.9%) and Ecuador (15/82, 18.3%).The reason for the trip was reported in 303 cases (60.0%); the most frequent was to visit relatives or friends (VRF), 163 (53.8%) cases, followed by tourism, 80 (26.4%) cases. A higher frequency of VRF was observed in those who contracted the infection in South American countries, while travel by tourism was more frequent in those who were infected in Central America and the Caribbean (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>The majority of confirmed cases (286/349, 81.9%) were diagnosed by genome detection in serum or urine. In 13 cases there was coinfection due to dengue or chikungunya virus.Excluding cases of congenital infection by ZV, information on clinical data was available in 268 cases (52.9%). The most frequent symptoms were rash (86.0%) and fever (69.1%). In two cases, non-obstetric neurological complications were reported: one case was compatible with Guillain-Barré and another with polyneuropathy. Hospitalisation occurred in 33 cases (6.5%, 95% CI: (4.5–9.0)). No death was reported.Infection in pregnant women and neonatal casesA total of 86 females aged 16–42 years (median 29 years) were pregnant at the time of sampling. One female patient had been infected through intercourse. The most frequent contagion countries were the Dominican Republic (30, 34.9%) and Honduras (14, 16.3%). Of the 75 women with known data, 20 (26.7%) were in the first trimester of pregnancy, 42 (56.0%) in the second and 13 (17.3%) in the third.Information of the pregnancy duration was available in 85 of the 86 women. Pregnancy was completed in 75 cases (88.2%, 95% CI: 79.4–94.2); of them: 74 gave birth to uninfected newborns and one was born with microcephaly and was diagnosed with confirmed congenital Zika; six females (7.1%; 95% CI: 2.6–14.7) underwent voluntary interruptions of pregnancy; two of those foetuses were diagnosed with congenital Zika confirmed by laboratory and there was no microbiological information available for the other four. Finally, four of the 85 women (4.7%, 95% CI: 1.3–11.6) had spontaneous abortions; there is no available information on those embryos or foetuses.The proportion of pregnancies with confirmed congenital Zika, in those with information regarding the neonate, foetus or embryo was 3.9% (3/77), 95% CI: 0.8–11.0. Three women were exposed during their first trimester of pregnancy, one did not present symptoms of illness and was diagnosed during a routine control of her pregnancy, and another was aged over 40 and co-infected with dengue virus.In addition, two other congenital cases were reported to have been born to newly arrived immigrant women whose disease was not diagnosed in Spain, such that they were not included in this analysis.DiscussionZVD surveillance began in Spain in 2016, and cases were reported from week 49 of 2015. 79.5% of the cases corresponded to 2016, peaking in week 33 and subsequently decreasing. 64.5% of patients were female and the median age was 34. The majority of the cases resided in Spain and, although we did not know the place of birth and the reason for the trip in a high percentage, around 30% of the cases were of Latin American origin and travelled to VRF. In 96% of the cases infection occurred in Latin America. Cases occurred most frequently in Catalonia and Madrid, which also had the highest rates, along with La Rioja. The presentation of the cases was benign and their evolution was favourable, with less than 10% of hospitalisations. One case of Guillain-Barré syndrome and three cases (3.9%) of congenital infection were detected in pregnant women.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">4,13</a> and with that described by other studies on imported cases of ZVD and other diseases.<a class="elsevierStyleCrossRefs" href="#bib0220">14,15</a> It is important to note the close historical and cultural relationship between Spain and Latin America. According to the Statistical Institute of Spain, in 2017 2,419,842 people born in Latin American countries (nationalised or not) lived in Spain, with a femininity index of 135. These people make and receive frequent visits to their places of origin. In addition, Latin America is a common tourist destination for Spaniards. The number of travellers from the Americas (not including North America) in 2016 and 2017 was 2,572,071 and 3,236,407, respectively. Spain received 105,866 immigrants born in Latin America in 2015 out of a total of 342,114.<a class="elsevierStyleCrossRef" href="#bib0230">16</a>Catalonia and Madrid, both with high numbers of international travellers and a large number of non-Spanish residents concentrated in large cities, had the highest number of notifications. In regard to Catalonia, 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 A. albopictus and in implementing an arbovirosis surveillance and control programme.<a class="elsevierStyleCrossRef" href="#bib0235">17</a>A total of 267 of the 328 women were of childbearing age (81.4% vs. 44.8% in the general population in 2017) and 86 (26.2%) were pregnant. The overrepresentation of women and the high proportion of pregnant women is also observed in other case studies of ZVD.<a class="elsevierStyleCrossRefs" href="#bib0240">18–21</a> This could be explained by the fact that this population group more often requests diagnostic tests given the risk of foetal malformations, and that there are more Latin America women residents in Spain than men. Another possible explanation could be that women presented a higher risk of disease, although a seroprevalence study conducted into an outbreak on Yap Island found that risk of infection was higher in men.<a class="elsevierStyleCrossRef" href="#bib0250">20</a>A high proportion of ZVD cases contracted the infection during VRF. This group of people plan less for trips, stay longer and travel to more insecure areas, so are thus more likely to suffer from mosquito bites, such that the risk of getting sick exceeds that of other tourists.<a class="elsevierStyleCrossRef" href="#bib0260">22</a> Previous studies reveal that those travelling to VRF ask fewer questions about the location they are travelling to.<a class="elsevierStyleCrossRef" href="#bib0265">23</a> In addition, according to studies conducted in the United States and Europe, their primary source of health information for these travellers are primary care doctors.<a class="elsevierStyleCrossRefs" href="#bib0270">24,25</a> In Spain, the health services most used by immigrants are the primary care and emergency departments.<a class="elsevierStyleCrossRef" href="#bib0280">26</a> All this reinforces the need to establish or support strategies aimed at this risk group, from general medicine and emergency departments, and all other health units.The frequency of symptoms, rash in 86.0% and fever in 69.1% of known clinical cases, is largely due to the fact that they are part of the clinical criteria that defines a case. The frequency of hospitalisation (6.5%, 4.5–9.0) was higher than that of a study in Colombia (4%) and similar to that of France (5%).<a class="elsevierStyleCrossRefs" href="#bib0240">18,19</a>The proportion of foetal alterations associated with Zika infection during pregnancy (3.9%, 95% CI: 0.8–11.0) was lower than that found in pregnant women in the United States (4–6%),<a class="elsevierStyleCrossRef" href="#bib0285">27</a> although our estimate was imprecise due to a smaller sample size.Surveillance of ZVD began shortly after the alert was generated,<a class="elsevierStyleCrossRef" href="#bib0290">28</a> so there could be differences between each AR notification capacity after detection. In addition, certain variables presented high percentages of lost data. Furthermore, the inclusion of probable cases could overestimate the number of cases. Finally, due to the absence of an adequate denominator of the population at risk of contracting ZVD, the resident population could only be adjusted by AR. However, 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. All regions except Cantabria reported cases in the first year, and only Ceuta and Melilla did not detect any cases, so the establishment of the process seems to have been homogeneous. The absence of diagnostic tools most probably did not limit the process, as the National Centre of Microbiology was available from the beginning. Missing data offer an opportunity for improvement for a more accurate description of the ZVD epidemiology in our context, and it was not a limitation for this study, as no association between the variables was explored.RENAVE is the only source of ZVD cases in all areas (including outpatient) and has national reach. Although under-reporting is assumed,<a class="elsevierStyleCrossRef" href="#bib0295">29</a> reported cases in general would be representative of those diagnosed in our setting. Our results could be partially extrapolated to other regions with similar characteristics, except in aspects such as the origin of cases – whose pattern depends on the relationships with countries with indigenous transmission – and for certain estimates which were not precise, making their comparison difficult.Since 2007, outbreaks of dengue fever and chikungunya fever transmitted locally by A. albopictus have occurred in Europe, the latests have been in Spain and France.<a class="elsevierStyleCrossRef" href="#bib0300">30</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.<a class="elsevierStyleCrossRefs" href="#bib0255">21,28</a> However, due to the presence of a vector, a susceptible population – considering pregnant women to be a group that is of special risk – and a considerable number of people in the viremic phase in places and during periods of activity of A. albopictus in Spain, surveillance is essential.<a class="elsevierStyleCrossRefs" href="#bib0195">9,28</a> Additionally, entomological surveillance allows us to identify new areas colonised by mosquitoes and to deepen our knowledge on their transmissibility potential. Finally, the surveillance of imported diseases has proven to be useful as global sentinel surveillance, especially in the case of diseases that circulate in places where circumstances do not favour their detection.<a class="elsevierStyleCrossRefs" href="#bib0220">14,15</a>Conflict of interestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1211921" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1127992" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1211920" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1127991" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Infection in pregnant women and neonatal cases" ] ] ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-08-09" "fechaAceptado" => "2018-12-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1127992" "palabras" => array:3 [ 0 => "Zika virus" 1 => "Surveillance" 2 => "Spain" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1127991" "palabras" => array:3 [ 0 => "Virus Zika" 1 => "Vigilancia" 2 => "España" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Introduction and objectiveZika virus disease is a challenge for public health due to its rapid spread and potential foetal complications. Although it is imported in Spain, there is a risk of autochthonous transmission due to Aedes albopictus presence. Zika disease and congenital cases have been under surveillance since 2016. The objective of this study is to explore the epidemiology of disease and pregnancies result. Material and methodsA descriptive study was carried out into cases reported to the National Surveillance Network (RENAVE) during the 30/11/2015 to 31/12/2017 period. The case definition and the survey are included in the RENAVE protocol. The variables were: date; notifying region (Autonomous Community (AC)); pregnancy and its evolution; case classification; mode of transmission; country or region of infection; socio-demographical, clinical and microbiological data. A descriptive analysis of the cases and their distribution according to the other variables was carried out. ResultsA total of 512 cases were reported by 17 ACs. 507 were non-congenital, of which 327 (64.5%) were women (52.5% of childbearing age). 403 cases (79.5%) corresponded to 2016 and 193 (38.1%) resided in regions with A. albopictus presence between May and October. 96.1% of imported cases were infected in America (51.7% while visiting relatives). Three cases (3.9%) of congenital Zika virus infection were detected among 77 pregnant women. ConclusionsThe evolution of reported cases was in accordance with that of the epidemic in America. The largest group of travellers was young women who travelled to Latin America on family visits. Pregnancy monitoring resulted in the identification of Zika related foetal complications." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Introducción y objetivoLa enfermedad por virus Zika constituye un reto para la salud pública por su rápida expansión y sus potenciales complicaciones fetales. En España la enfermedad por virus Zika es importada, aunque la presencia de Aedes albopictus no descarta su transmisión autóctona. La enfermedad por virus Zika y los casos congénitos se vigilan desde 2016. El objetivo es conocer su epidemiología y el resultado de la gestación en las embarazadas. Material y métodosEstudio descriptivo de casos notificados a la Red Nacional de Vigilancia Epidemiológica (RENAVE) entre el 30/11/2015 y el 31/12/2017. La definición de caso y la encuesta se recogen en los protocolos de la RENAVE. Las variables fueron: fecha, comunidad autónoma (CC.AA.), clasificación, modo y lugar de infección, variables sociodemográficas, clínicas, microbiológicas, embarazo y su evolución. Se realizó un análisis descriptivo de los casos y su distribución según el resto de variables. ResultadosDiecisiete CC.AA. notificaron 512 casos, de los cuales 507 fueron no congénitos: 327 (64,5%) eran mujeres (52,5% en edad fértil); 403 casos (79,5%) correspondieron a 2016 y 193 (38,1%) residían en CC.AA. colonizadas por A. albopictus entre mayo y octubre. El 96,1% de casos importados se infectaron en América y el 51,7% en visitas familiares. Se detectaron 3 casos de infección congénita en 77 embarazadas. ConclusionesLa evolución de notificaciones mostró paralelismo con la de la epidemia en América. El grupo más numeroso de viajeros fue el de mujeres jóvenes que fueron a Latinoamérica en visitas familiares. El seguimiento de las embarazadas permitió identificar complicaciones fetales." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "◊" "nota" => "The names of the components of the RENAVE group are related in <a class="elsevierStyleCrossRef" href="#sec0035">Annex</a>." "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Fernández Martínez B, Martínez Sánchez EV, Díaz García O, Gómez Barroso D, Sierra Moros MJ, Cano Portero R, et al. La enfermedad por virus Zika en España. Resultados de la vigilancia y epidemiología de los casos notificados en 2015-2017. Med Clin (Barc). 2019;153:6–12." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "Andalusia: Mercedes Pérez Ruiz (Virgen de las Nieves University Hospital, Microbiology Service); Enric Durán Plá (Regional Ministry for Health, Surveillance and Labour Health Service). Aragon: Ana Delia Cebollada Gracia and Alberto Vergara Ugarriza (General Directorate of Public Health). Asturias: Ismael Huerta González (Epidemiological Surveillance Service, General Directorate of Public Health). Balearic Islands: Paula Grau Sancho and Isabel Cataliba Bosch (Epidemiology Service, General Directorate of Public Health and Participation). Canary Islands: Magdalena L. Rojo Moreno and Alicia Pla Francés (General Directorate of Public Health). Cantabria: Aniceto Blasco de la Fuente and Luis Javier Viloria Raymundo (Regional Ministry of Health, Epidemiological Surveillance Section). Castile and León: Cristina Ruiz Sopeña and Socorro Fernández Arribas (Regional Ministry of Health, Epidemiology Service, General Directorate of Public Health). Castilla-La Mancha: Pilar Peces Jimenez (General Directorate of Public Health, Health Information and Epidemiological Surveillance Service). Catalonia: Núria Torner Gràcia and Mireia Jané Checa (Public Health, Epidemiological Control, Surveillance and Emergency Response Services). Coordination Centre for Health Alerts and Emergencies: Berta Suárez Rodríguez. Berta Suárez Rodríguez (Coordination Centre for Health Alerts and Emergencies. Ministry of Health, Consumption and Social Welfare). María Paz Sánchez-Seco Fariña (National Centre of Microbiology, Carlos III Health Institute). Ceuta: Ana I. Rivas Pérez (Regional Ministry of Health, Epidemiological Surveillance Service). Extremadura: Julián Mauro Ramos Aceitero (General Directorate of Public Health, Subdirectorate of Epidemiology). Galicia: Ánxela Pousa Ortega and María Jesús Purriños Hermida (General Directorate of Public Health, Epidemiology Services). Madrid: Alba Nieto Juliá and Pello Latasa Zamalloa (General Directorate of Public Health, Epidemiology Service). Melilla: Daniel Castrillejo Pérez (Regional Ministry of Public Health, Epidemiology Service). Murcia: Visitación Garcia Ortúzar (General Directorate of Public Health, Epidemiological Surveillance). Navarra Itziar Casado and Jesús Castilla (Navarra Institute of Public Health, CIBERESP). Basque Country: Fernando González-Carril and Jose María Artegoitia Axpe (Directorate of Public Health and Addictions, Epidemiological Surveillance Service and Vaccines). La Rioja: Eva Martínez Ochoa and Ana Carmen Ibáñez Pérez (General Directorate of Public Health and Consumption, Epidemiology and Health Prevention Service). Valencian Community: Isabel Huertas Zarco and Katja Villatoro Bongiorno (Regional Ministry of Health, Sub-Directorate General of Epidemiology and Health Surveillance)." "etiqueta" => "Annex" "titulo" => "RENAVE group components (listed alphabetically by AR or body)" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2125 "Ancho" => 3167 "Tamanyo" => 453790 ] ] "descripcion" => array:1 [ "en" => "Temporal evolution of the worldwide spread of the Zika virus. 1947–2016." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1625 "Ancho" => 2547 "Tamanyo" => 193072 ] ] "descripcion" => array:1 [ "en" => "Autonomous Regions (AR) colonised by Aedes albopictus (in at least one municipality) according to year and distribution of reported Zika virus disease (ZVD) cases according to AR. Spain, 2015–2017." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1358 "Ancho" => 2478 "Tamanyo" => 170017 ] ] "descripcion" => array:1 [ "en" => "Temporal distribution of Zika virus disease cases according to classification. Spain, 2015–2017." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1256 "Ancho" => 2196 "Tamanyo" => 99402 ] ] "descripcion" => array:1 [ "en" => "Distribution of Zika virus disease cases imported from Latin America by region of infection according to reason for travel. Spain, 2015–2017. *VRF: visit family and friends." ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "VRF: visit family and friends." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 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 " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable</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">n (%) \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="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex</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">Male \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">178 (35.1) \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">Female \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">327 (64.5) \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 \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">2 (0.4) \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="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age groups (years)</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">0–14 \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">27 (5.4) \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">15–24 \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">67 (13.2) \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">25–34 \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">166 (32.7) \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">35–44 \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">138 (27.2) \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">45–54 \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">59 (11.6) \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">>54 \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 (7.9) \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 \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 (2.0) \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 \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 (96.6) \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 \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 (2.8) \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 \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 (0.6) \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 \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 (29.4) \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 \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 (22.7) \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 (Europe) \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 (0.6) \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 \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 (47.3) \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">a</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 \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 (32.3) \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 \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 (15.8) \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 \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 (5.1) \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 \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 (4.2) \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 \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 (2.6) \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 \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 (40.0) \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">a</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 \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 (34.6) \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 \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 (33.9) \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 \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 (24.4) \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">b</a> \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 (4.2) \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 \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 (3.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2068982.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "n=505 (excludes 2 not imported cases)." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Asia (n=13), Africa (n=6), United States (n=2)." ] ] ] "descripcion" => array:1 [ "en" => "Main characteristics of Zika virus disease cases (excludes congenital cases). Spain, 2015–2017." ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 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"> \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"> \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">n (%)</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 (95% CI)</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"> \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"> \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 \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 \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 \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 \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 Aedes albopictus</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 \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 (5.0) \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 (3.3) \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">0.21 (0.13–0.32) \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">0.03 (0.01–0.09) \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 \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 (5.2) \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 (1.1) \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">0.98 (0.61–1.50) \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">0.04 (0.00–0.25) \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 \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 (1.7) \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 (1.1) \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">0.58 (0.23–1.20) \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">0.07 (0.00–0.41) \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 \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 (35.5) \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 (58.9) \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">1.92 (1.62–2.26) \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">0.71 (0.53–0.93) \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. \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 (3.7) \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 (3.3) \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">0.30 (0.17–0.49) \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">0.06 (0.01–0.17) \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 \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 (0.5) \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 (1.1) \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">0.21 (0.03–0.76) \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">0.10 (0.00–0.55) \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 \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 (6.0) \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 (3.3) \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">1.38 (0.88–2.05) \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">0.17 (0.03–0.48) \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 A. albopictus</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 \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 (2.5) \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 \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">0.70 (0.34–1.29) \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"> \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 \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 (2.0) \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 (2.2) \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">0.44 (0.19–0.87) \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">0.11 (0.01–0.39) \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 \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 \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 (1.1) \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"> \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">0.10 (0.00–0.58) \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 León \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 (4.0) \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 \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">0.44 (0.25–0.71) \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"> \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 \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 (1.5) \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 \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">0.34 (0.13–0.74) \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"> \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 \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 (0.5) \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 (1.1) \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">0.18 (0.02–0.65) \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">0.09 (0.00–0.49) \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 \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 (3.0) \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 (2.2) \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">0.39 (0.20–0.70) \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">0.06 (0.01–0.23) \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 \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 (25.6) \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 (18.9) \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">1.65 (1.35–2.00) \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">0.27 (0.16–0.43) \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">Navarra \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 (1.5) \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 (1.1) \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">0.83 (0.31–1.81) \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">0.13 (0.00–0.75) \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">The Rioja \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 (2.0) \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 (1.1) \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">1.71 (0.74–3.37) \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">0.21 (0.00–1.17) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total Spain</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">403 \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">90 \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">0.81 (0.74–0.90) \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">0.18 (0.14–0.22) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2068981.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "Rates calculated for years with complete data for the entire period (2016 and 2017)." ] ] ] "descripcion" => array:1 [ "en" => "Zika virus cases and rates of disease. Distribution by AR of residence. Spain, 2016 and 2017.<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "History, epidemiology, and clinical manifestations of Zika: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E.S. Paixão" 1 => "F. Barreto" 2 => "M. da Glória Teixeira" 3 => "N. da Conceição" 4 => "M. Costa" 5 => "L.C. 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Original article

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

La enfermedad por virus Zika en España. Resultados de la vigilancia y epidemiología de los casos notificados en 2015-2017

Beatriz Fernández Martíneza,b,

Corresponding author

beafmar@gmail.com
bfernandez@isciii.es

Corresponding author.

, Elena V. Martínez Sáncheza,b, Oliva Díaz Garcíaa, Diana Gómez Barrosoa,b, M. José Sierra Morosc, Rosa Cano Porteroa,b, on behalf of the National Network of Epidemiological Surveillance (RENAVE) ◊

a Área de Análisis en Vigilancia Epidemiológica, Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain

b Consorcio de Investigación Biomédica de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain

c Centro de Coordinación de Alertas y Emergencias Sanitarias, Ministerio de Sanidad, Consumo y Bienestar Social, Madrid, Spain

Components of the RENAVE group (in alphabetical order of CC.AA.)

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Zika virus disease &#40;ZVD&#41; is considered one of the main emerging pathologies of the 20th century and a serious challenge for public health in the world&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Zika virus &#40;ZV&#41; was first isolated in Uganda in 1947 in a rhesus macaque and soon after in humans&#44; but the first major epidemic was not documented until 2007&#44; on the island of Yap&#44; followed by others in different locations in the Pacific in 2013 and 2014&#46; Until then&#44; it was not considered a relevant human pathogen&#46; It is now known that the virus circulated in humans since its discovery in Africa and Asia&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#8211;3</span></a> ZV was immediately associated with the Brazilian epidemic in 2015 and suspected to be related to the increase in cases of microcephaly&#46; 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; 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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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        "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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        "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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      1 => array:2 [
        "etiqueta" => "&#9734;"
        "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 ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">45&#8211;54&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&#62;54&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \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"
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              "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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                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
                  \t\t\t\t">1&#46;65 &#40;1&#46;35&#8211;2&#46;00&#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;27 &#40;0&#46;16&#8211;0&#46;43&#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">Navarra&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">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;83 &#40;0&#46;31&#8211;1&#46;81&#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;13 &#40;0&#46;00&#8211;0&#46;75&#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">The Rioja&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">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">1&#46;71 &#40;0&#46;74&#8211;3&#46;37&#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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