National Epidemiological Surveillance Network Research Articles

The Temporary Incapacity (TI) register as a complementary system to traditional epidemiological surveillance during the COVID-19 pandemic in Spain.

During the COVID-19 pandemic, a set of social measures were adopted for the preservation of business activity and the protection of workers. One of these measures was issuing the Temporary Disability (TD) for COVID-19 cases, close contacts, and especially vulnerable workers. This study analyzes whether the TD registry could be used as a complementary source to traditional epidemiological surveillance. A longitudinal study of time series was carried out with a cross-correlation analysis of TD and COVID-19 cases reported to the National Epidemiological Surveillance Network (RENAVE). The analysis included six pandemic waves between 10/03/2020 and 31/12/2021 in Spain. Cross-correlation coefficients (r) were calculated using a time lag of -14 days. During the study period, 2,253,573 TD processes were recorded in Spain and 4,894,802 COVID-19 cases were reported to RENAVE. Significant positive correlations were observed at time lags of -7, -10, and -14, indicating that TD notification preceded RENAVE notification. In the first and sixth pandemic waves, TD notification preceded RENAVE by 12 and 7 days, respectively. Negative correlations between the two series were observed in the second and fourth waves, coinciding with a lower number of reported cases. In the third and fifth waves, TD notification also preceded RENAVE (lags -1, -5 and -14, -7, respectively). The results confirm the usefulness of TD registry as a complementary system to traditional epidemiological surveillance in Spain, by detecting COVID-19 cases in the 7, 10, and 14 days prior. A better positive correlation is observed in waves where more cases were reported.

The epidemiological situation of tuberculosis in Spain according to surveillance and hospitalization data, 2012-2020.

Before the COVID-19 pandemic, tuberculosis (TB) was the leading cause of death from a single infectious agent. In Spain, TB notifications are registered through the National Epidemiological Surveillance Network (RENAVE). The Minimum Basic Data Set (CMBD) provides information on TB hospital discharges. This study aims to assess both registries to complete the picture of TB in order to improve national control strategies and make further progress toward its elimination. A retrospective study was performed considering CMBD´s hospital discharges with TB as first diagnosis and notifications to RENAVE between 2012 and 2020. After describing the records of both systems and their differences by using descriptive and multivariate analysis, annual incidences rates were calculated in order to evaluate temporal trends and geographical patters. According to the CMBD database, there were 29,942 hospitalizations due to TB (65% pulmonary forms and 66% male) during the study period. RENAVE collected 44,520 reported cases, mostly males (62%) with pulmonary forms (72%). Young children were similar in both groups, showing the high frequency of hospitalization in this group. Almost all autonomous communities showed a downward trend, especially Asturias. Hospitalizations in 2020 were analyzed by month separately, and comparing with previous years, the impact of the COVID-19 pandemic can be seen. A decreasing trend on TB incidence was observed in Spain since 2012, although this trend might change after COVID-19 pandemic. The analysis of both databases, CMBD and RENAVE, has contributed to improve our knowledge of TB in Spain and will help improve the control of this disease.

The impact of meteorological factors on tuberculosis incidence in Spain: a spatiotemporal analysis.

Tuberculosis (TB) remains a global leading cause of death, necessitating an investigation into its unequal distribution. Sun exposure, linked to vitamin D (VD) synthesis, has been proposed as a protective factor. This study aimed to analyse TB rates in Spain over time and space and explore their relationship with sunlight exposure. An ecological study examined the associations between rainfall, sunshine hours, and TB incidence in Spain. Data from the National Epidemiological Surveillance Network (RENAVE in Spanish) and the Spanish Meteorological Agency (AEMET in Spanish) from 2012 to 2020 were utilized. Correlation and spatial regression analyses were conducted. Between 2012 and 2020, 43,419 non-imported TB cases were reported. A geographic pattern (north-south) and distinct seasonality (spring peaks and autumn troughs) were observed. Sunshine hours and rainfall displayed a strong negative correlation. Spatial regression and seasonal models identified a negative correlation between TB incidence and sunshine hours, with a four-month lag. A clear spatiotemporal association between TB incidence and sunshine hours emerged in Spain from 2012 to 2020. VD levels likely mediate this relationship, being influenced by sunlight exposure and TB development. Further research is warranted to elucidate the causal pathway and inform public health strategies for improved TB control.

An interregional measles outbreak in Spain with nosocomial transmission, November 2017 to July 2018.

Given sustained high vaccination coverage and enhanced surveillance for measles, Spain has been free of endemic measles transmission since 2014, achieving elimination certification from the World Health Organization in 2017. In November 2017, measles was introduced through an imported case travelling to the Valencian Community, causing an interregional outbreak. Here, we describe the outbreak using data reported to the national epidemiological surveillance network. The outbreak involved 154 cases (67 males, 87 females) notified in four regions; 148 were laboratory-confirmed and six epidemiologically linked. Most cases were adults aged 30-39 (n = 62, 40.3%) years. Sixty-two cases were hospitalised (40.3%) and 35 presented complications (22.7%). Two thirds of the cases (n = 102) were unvaccinated including 11 infants (≤ 1 year) not yet eligible for vaccination. The main route of transmission was nosocomial; at least six healthcare facilities and 41 healthcare workers and support personnel were affected. Sequencing of the viral nucleoprotein C-terminus (N450) identified genotype B3, belonging to the circulating MVs/Dublin.IRL/8.16-variant. Control measures were implemented, and the outbreak was contained in July 2018. The outbreak highlighted that raising awareness about measles and improving the vaccination coverage in under-vaccinated subgroups and personnel of healthcare facilities are key measures for prevention of future outbreaks.

Comparative severity of COVID-19 cases caused by Alpha, Delta or Omicron SARS-CoV-2 variants and its association with vaccination

BackgroundThis study compares the severity of SARS-CoV-2 infections caused by Alpha, Delta or Omicron variants in periods of co-circulation in Spain, and estimates the variant-specific association of vaccination with severe disease. MethodsSARS-CoV-2 infections notified to the national epidemiological surveillance network with information on genetic variant and vaccination status were considered cases if they required hospitalisation or controls otherwise. Alpha and Delta were compared during June–July 2021; and Delta and Omicron during December 2021–January 2022. Adjusted odds ratios (aOR) were estimated using logistic regression, comparing variant and vaccination status between cases and controls. ResultsWe included 5,345 Alpha and 11,974 Delta infections in June–July and 5,272 Delta and 10,578 Omicron in December–January. Unvaccinated cases of Alpha (aOR: 0.57; 95% CI: 0.46–0.69) or Omicron (0.28; 0.21–0.36) had lower probability of hospitalisation vs. Delta. Complete vaccination reduced hospitalisation, similarly for Alpha (0.16; 0.13–0.21) and Delta (June–July: 0.16; 0.14–0.19; December–January: 0.36; 0.30–0.44) but lower from Omicron (0.63; 0.53–0.75) and individuals aged 65+ years. ConclusionResults indicate higher intrinsic severity of the Delta variant, compared with Alpha or Omicron, with smaller differences among vaccinated individuals. Nevertheless, vaccination was associated to reduced hospitalisation in all groups.

Spanish wastewater reveals the current spread of Monkeypox virus

Besides nasopharyngeal swabs, monkeypox virus (MPXV) DNA has been detected in a variety of samples such as saliva, semen, urine and fecal samples. Using the environmental surveillance network previously developed in Spain for the routine wastewater surveillance of SARS-CoV-2 (VATar COVID-19), we have analyzed the presence of MPXV DNA in wastewater from different areas of Spain. Samples (n=312) from 24 different wastewater treatment plants were obtained between May 9 (week 19 of 2022) and August 4 (week 31 of 2022). Following concentration of viral particles by a validated aluminum adsorption-precipitation method, a qPCR procedure allowed us to detect MPXV DNA in 56 wastewater samples collected from May 16 to August 4, 2022, with values ranging between 2.2×103 to 8.7×104 genome copies (gc)/L. This study shows that MPXV DNA can be reproducibly detected by qPCR in longitudinal samples collected from different Spanish wastewater treatment plants. According to data from the National Epidemiological Surveillance Network (RENAVE) in Spain a total of 6,119 cases have been confirmed as of August 19, 2022. However, and based on the wastewater data, the reported clinical cases seem to be underestimated and asymptomatic infections may be more frequent than expected.

Epidemiological Characteristics and Spatio-Temporal Distribution of Hepatitis A in Spain in the Context of the 2016/2017 European Outbreak.

The aim of our study was to describe the results of the epidemiological surveillance of hepatitis A infections in Spain in the context of the 2016/2017 European outbreak, particularly of hepatitis A outbreaks reported in the MSM population, incorporating the results of a spatio-temporal analysis of cases. Hepatitis A cases and outbreaks reported in 2016-2017 to the National Epidemiological Surveillance Network were reviewed: outbreaks in which some of the cases belonged to the MSM group were described, and clusters of hepatitis A cases in men and women were analysed using a space-time scan statistic. Twenty-six outbreaks were identified, with a median size of two cases per outbreak, with most of the outbreak-related cases belonging to the 15-44 years-old group. Nearly 85% occurred in a household setting, and in all outbreaks, the mode of transmission was direct person-to-person contact. Regarding space-time analysis, twenty statistically significant clusters were identified in the male population and eight in the female population; clusters in men presented a higher number of observed cases and affected municipalities, as well as a higher percentage of municipalities classified as large urban areas. The elevated number of cases detected in clusters of men indicates that the number of MSM-related outbreaks may be higher than reported, showing that spatio-temporal analysis is a complementary, useful tool which may improve the detection of outbreaks in settings where epidemiological investigation may be more challenging.

Comparative severity of COVID-19 cases caused by Alpha, Delta or Omicron SARS-CoV-2 variants and its association with vaccination

BackgroundThis study compares the severity of SARS-CoV-2 infections caused by Alpha, Delta or Omicron variants in periods of co-circulation in Spain, and estimates the variant-specific association of vaccination with severe disease. MethodsSARS-CoV-2 infections notified to the national epidemiological surveillance network with information on genetic variant and vaccination status were considered cases if they required hospitalisation or controls otherwise. Alpha and Delta were compared during June–July 2021; and Delta and Omicron during December 2021–January 2022. Adjusted odds ratios (aOR) were estimated using logistic regression, comparing variant and vaccination status between cases and controls. ResultsWe included 5,345 Alpha and 11,974 Delta infections in June–July and 5,272 Delta and 10,578 Omicron in December–January. Unvaccinated cases of Alpha (aOR: 0.57; 95% CI: 0.46–0.69) or Omicron (0.28; 0.21–0.36) had lower probability of hospitalisation vs. Delta. Complete vaccination reduced hospitalisation, similarly for Alpha (0.16; 0.13–0.21) and Delta (June–July: 0.16; 0.14–0.19; December–January: 0.36; 0.30–0.44) but lower from Omicron (0.63; 0.53–0.75) and individuals aged 65+ years. ConclusionResults indicate higher intrinsic severity of the Delta variant, compared with Alpha or Omicron, with smaller differences among vaccinated individuals. Nevertheless, vaccination was associated to reduced hospitalisation in all groups.

Influence of weather factors on the incidence of COVID-19 in Spain

IntroductionSeveral studies have analyzed the influence of meteorological and geographical factors on the incidence of COVID-19. Seasonality could be important in the transmission of SARS-CoV-2. This study aims to evaluate the geographical pattern of COVID-19 in Spain and its relationship with different meteorological variables. MethodsA provincial ecological study analyzing the influence of meteorological and geographical factors on the cumulative incidence of COVID-19 in the 52 (24 coastal and 28 inland) Spanish provinces during the first three waves was carried out. The cumulative incidence was calculated with data from the National Statistical Institute (INE) and the National Epidemiological Surveillance Network (RENAVE), while the meteorological variables were obtained from the Spanish Meteorological Agency (AEMET). ResultsThe total cumulative incidence, in all three waves, was lower in the coastal provinces than in the inland ones (566 ± 181 vs. 782 ± 154; P = 2.5 × 10−5). The cumulative incidence correlated negatively with mean air temperature (r = −0.49; P = 2.2 × 10−4) and rainfall (r = −0.33; P = .01), and positively with altitude (r = 0.56; P = 1.4 × 10−5). The Spanish provinces with an average temperature <10 °C had almost twice the cumulative incidence than the provinces with temperatures >16 °C. The mean air temperature and rainfall were associated with the cumulative incidence of COVID-19, regardless of other factors (Beta Coefficient of −0.62; P = 3.7 × 10−7 and −0.47; P = 4.2 × 10−5 respectively) ConclusionsMeteorological and geographical factors could influence the evolution of the pandemic in Spain. Knowledge regarding the seasonality of the virus would help to predict new waves of COVID-19 infections

The Impact of COVID-19 on Mortality in Spain: Monitoring Excess Mortality (MoMo) and the Surveillance of Confirmed COVID-19 Deaths.

Measuring mortality has been a challenge during the COVID-19 pandemic. Here, we compared the results from the Spanish daily mortality surveillance system (MoMo) of excess mortality estimates, using a time series analysis, with those obtained for the confirmed COVID-19 deaths reported to the National Epidemiological Surveillance Network (RENAVE). The excess mortality estimated at the beginning of March 2020 was much greater than what has been observed in previous years, and clustered in a very short time. The cumulated excess mortality increased with age. In the first epidemic wave, the excess mortality estimated by MoMo was 1.5 times higher than the confirmed COVID-19 deaths reported to RENAVE, but both estimates were similar in the following pandemic waves. Estimated excess mortality and confirmed COVID-19 mortality rates were geographically distributed in a very heterogeneous way. The greatest increase in mortality that has taken place in Spain in recent years was detected early by MoMo, coinciding with the spread of the COVID-19 pandemic. MoMo is able to identify risk situations for public health in a timely manner, relying on mortality in general as an indirect indicator of various important public health problems.

Influencia de los factores meteorológicos en la incidencia de COVID-19 en España

IntroductionSeveral studies have analyzed the influence of meteorological and geographical factors on the incidence of COVID-19. Seasonality could be important in the transmission of SARS-CoV-2. This study aims to evaluate the geographical pattern of COVID-19 in Spain and its relationship with different meteorological variables. MethodsA provincial ecological study analyzing the influence of meteorological and geographical factors on the cumulative incidence of COVID-19 in the 52 (24 coastal and 28 inland) Spanish provinces during the first three waves was carried out. The cumulative incidence was calculated with data from the National Statistical Institute (INE) and the National Epidemiological Surveillance Network (RENAVE), while the meteorological variables were obtained from the Spanish Meteorological Agency (AEMET). ResultsThe total cumulative incidence, in all three waves, was lower in the coastal provinces than in the inland ones (566±181 vs. 782±154; p=2.5×10−5). The cumulative incidence correlated negatively with mean air temperature (r=−0.49; p=2.2×10−4) and rainfall (r=−0.33; p=0.01), and positively with altitude (r=0.56; p=1. 4×10−5). The Spanish provinces with an average temperature <10°C had almost twice the cumulative incidence than the provinces with temperatures >16°C. The mean air temperature and rainfall were associated with the cumulative incidence of COVID-19, regardless of other factors (Beta Coefficient of −0.62; p=3.7×10−7 and −0.47; p=4.2×10–5 respectively). ConclusionsMeteorological and geographical factors could influence the evolution of the pandemic in Spain. Knowledge regarding the seasonality of the virus would help to predict new waves of COVID-19 infections.

Monitorización de la COVID-19 en España: ¿es posible un análisis con perspectiva de género?

ObjectiveTo analyse the sex disaggregation and availability of gender indicators in the reports of the National Epidemiological Surveillance Network (RENAVE) and the National Study of Sero-Epidemiology (ENE-COVID-19). MethodPeer review of indicators available in 72 RENAVE reports and 4 rounds of the ENE-COVID-19 study to calculate the percentage of those disaggregated by sex and their variation over time. ResultsIn March 2021, 52.4% of RENAVE indicators were disaggregated by sex. From July 2020, 54% of disaggregated indicators ceased to be published and 23% lost their disaggregation. In the ENE-COVID-19 study, the 1st round 88,23% of the indicators are disaggregated and the 4th round 94,74%. The 2nd and 3rd round do not disaggregated by sex. ConclusionsThe RENAVE reports do not allow for a gender-sensitive analysis while the ENE-COVID-19 study provides the most information on social determinants.

Unprecedented increase of West Nile virus neuroinvasive disease, Spain, summer 2020.

Cases of West Nile neuroinvasive disease (WNND) in Spain increased in summer 2020. Here we report on this increase and the local, regional and national public health measures taken in response. We analysed data from regional surveillance networks and the National Epidemiological Surveillance Network, both for human and animal West Nile virus (WNV) infection. During the 2020 season, a total of 77 human cases of WNV infection (median age 65 years; 60% males) were detected in the south-west of Spain; 72 (94%) of these cases developed WNND, presenting as meningoencephalitis, seven of which were fatal. In the previous two decades, only six human cases of WNND were detected in Spain. Reduced activities for vector control this season, together with other factors, might have contributed to the massive increase. Public health measures including vector control, campaigns to raise awareness among physicians and the general population, and interventions to ensure the safety of donations of blood products, organs, cells and tissues were effective to reduce transmission. Going forward, maintenance of vector control activities and an update of the vector-borne diseases response plan in Spain is needed.

Infection fatality risk for SARS-CoV-2 in community dwelling population of Spain: nationwide seroepidemiological study

ObjectiveTo estimate the infection fatality risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), based on deaths with confirmed coronavirus disease 2019 (covid-19) and excess deaths from all causes.DesignNationwide seroepidemiological...

Lockdown measures and relative changes in the age-specific incidence of SARS-CoV-2 in Spain.

During the first months of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) epidemic in 2020, Spain implemented an initial lockdown period on 15 March followed by a strengthened lockdown period on 30 March when only essential workers continued to commute to work. However, little is known about the epidemic dynamics in different age groups during these periods.We used the daily number of coronavirus 2019 cases (by date of symptom onset) reported to the National Epidemiological Surveillance Network among individuals aged 15-19 years through 65-69 years. For each age group g, we computed the proportion PrE(g) of individuals in age group g among all reported cases aged 15-69 years during the pre-lockdown period (1-10 March 2020) and the corresponding proportion PrL(g) during two lockdown periods (initial: 25 March-3 April; strengthened: 8-17 April 2020). For each lockdown period, we computed the proportion ratios PR(g) = PrL(g)/PrE(g). For each pair of age groups g1, g2, PR(g1)>PR(g2) implies a relative increase in the incidence of detected SARS-CoV-2 infection in the age group g1 compared with g2 for the lockdown period vs. the pre-lockdown period.For the initial lockdown period, the highest PR values were in age groups 50-54 years (PR = 1.21; 95% CI: 1.12,1.30) and 55-59 years (PR = 1.19; 1.11,1.27). For the second lockdown period, the highest PR values were in age groups 15-19 years (PR = 1.26; 0.95,1.68) and 50-54 years (PR = 1.20; 1.09,1.31).Our results suggest that different outbreak control measures led to different changes in the relative incidence by age group. During the initial lockdown period, when non-essential work was allowed, individuals aged 40-64 years, particularly those aged 50-59 years, had a higher relative incidence compared with the pre-lockdown period. Younger adults/older adolescents had an increased relative incidence during the later, strengthened lockdown. The role of different age groups during the epidemic should be considered when implementing future mitigation efforts.

Last cases of rubella and congenital rubella syndrome in Spain, 1997–2016: The success of a vaccination program

With a highly immunized population, rubella infection in Spain is so low that the WHO has declared the elimination of rubella. Rubella in pregnant women is also very rare. The objective of this study is to describe the last cases of congenital rubella syndrome reported and recommend actions to maintain the status of the disease as eliminated.The CRS cases reported to the Spanish National Epidemiological Surveillance Network between 1997 and 2016 were studied, and the epidemiological, clinical, diagnostic and maternal characteristics of newborns with CRS described. The incidence of CRS was calculated using Birth Statistics from the Spanish National Statistics Agency (INE).Twenty-three cases of CRS were reported, 70% of which were associated with rubella outbreaks. The most common clinical conditions were heart disease (52.2%), deafness (39.1%) and cataracts (30.4%); 91.3% of cases were confirmed by laboratory testing. 70.0% were born from a non-vaccinated foreign mother, resident in Spain (cumulative rate incidence (CR): 1.1/100,000 births), with mothers coming from Africa (36.0%), Latin America (29.0%), Eastern Europe (21.0%) and Asia (14.0%). Six were born to Spanish mothers (CR: 0.08/ 100,000 births), the last of which were in 2005.The majority of CRS cases were born to unvaccinated immigrant women infected in Spain during rubella outbreaks. Universal vaccination in childhood is the most efficient strategy to prevent rubella. The limited circulation of the virus will, however, quickly lead to a loss of awareness about rubella among clinicians and epidemiologists. It is necessary to maintain protocols capable of identifying signs consistent with rubella in pregnant women and signs suggestive of congenital rubella in newborns.

Epidemiology of tuberculosis in Spain. Results obtained by the National Epidemiological Surveillance Network in 2015

The epidemiological surveillance data for tuberculosis in Spain in 2015 is analysed in this report. This information was gathered through cases reported to the Red Nacional de Vigilancia Epidemiológica [National Epidemiological Surveillance Network]. In addition, the update of the treatment of the cases reported in 2014 is included. The incidence rate of tuberculosis in 2015 was 10.59 cases per 100,000 inhabitants, 10% less than in 2014. This decrease was mainly due to the sustained decreased trend of pulmonary tuberculosis rates, from other locations and in adults, while for cases of tuberculous meningitis and in children the decrease is less marked, with a tendency to stabilisation. The percentage of cases born in other countries remains stable (approximately 30% of the total). Information on HIV status is available in 63% of cases, of which 7% were HIV-positive. Regarding the treatment results, 77% of the new lung cases confirmed by culture reported in 2014 had a satisfactory result, 6% died, and 11% did not have this information.

Epidemiología de la tuberculosis en España. Resultados obtenidos por la Red Nacional de Vigilancia Epidemiológica en el año 2015

The epidemiological surveillance data for tuberculosis in Spain in 2015 is analysed in this report. This information was gathered through cases reported to the Red Nacional de Vigilancia Epidemiológica [National Epidemiological Surveillance Network]. In addition, the update of the treatment of the cases reported in 2014 is included. The incidence rate of tuberculosis in 2015 was 10.59 cases per 100,000 inhabitants, 10% less than in 2014. This decrease was mainly due to the sustained decreased trend of pulmonary tuberculosis rates, from other locations and in adults, while for cases of tuberculous meningitis and in children the decrease is less marked, with a tendency to stabilization. The percentage of cases born in other countries remains stable (approximately 30% of the total). Information on HIV status is available in 63% of cases, of which 7% were HIV-positive. Regarding the treatment results, 77% of the new lung cases confirmed by culture reported in 2014 had a satisfactory result, 6% died, and 11% did not have this information.

Three decades of hospital epidemiology and the challenge of integrating Health Surveillance: reflections from a case study.

This study proposes a reflection on the uses and future prospects of hospital-based health surveillance based on the account of a pioneering experience in hospital epidemiology, the epidemiology service at the Hospital Federal dos Servidores do Estado - HFSE, which served as the basis for the creation of epidemiologic surveillance units in municipal and state hospitals in Rio de Janeiro, Brazil. The epidemiology service has combined epidemiological surveillance, continuing education, in-service training, research, and health service evaluation since 1986. The service is part of the national epidemiological surveillance network and was responsible for the notification of 55,747 cases between 1986 and 2016, most of which were the result of active search. The integration of various levels of health surveillance and health care makes classical control activities more agile and provides instruments for measuring. The important role played by the service in human resources training is evident in the training of 1,835 medical interns and 78 residents up to 2016. In addition, this experience has served as the basis for the implantation of several other hospital epidemiological surveillance units. Current challenges include the promotion of effective communication and coordination among the other health surveillance committees.

Spatio-temporal analysis of tuberculosis in Spain, 2008–2010

The characteristics of respiratory tuberculosis (TB) favour the appearance of clusters of cases in space and time. It is important for public health authorities to know which clusters occur randomly and which merit further investigation. To detect spatial and spatio-temporal clusters of respiratory TB in Spain during the period from 1 January 2008 to 31 December 2010. Retrospective spatio-temporal study of respiratory TB cases reported to Spain's National Epidemiological Surveillance Network from 2008 to 2010, at a municipal level. We used the purely spatial and space-time Scan statistic estimators. All analyses were adjusted for age and sex. The spatial cluster analysis detected 28 significant clusters and the spatio-temporal cluster analysis detected 20 significant clusters. The most likely spatial cluster comprised seven municipalities in the Greater Barcelona Area. Most space-time clusters were situated in the same area, and were detected between 1 April 2008 and 31 March 2009. The distribution of TB clusters as shown by the proposed models furnishes a spatial pattern of the distribution of the disease. The two methods used can be a useful tool for analysing the distribution of respiratory TB in Spain.