Trichinellosis outbreaks are common in Spain, with disease rates comparable to those reported in the United States during the mid-twentieth century. [1,2] See graph:

Prevalence surveys:
0.3% of red foxes (Vulpes vulpes) in Catalonia (Trichinella britovi, 1998 to 2007)
8.9% of red foxes in Guadelajara (2000 publication)
3% of red foxes and 0.48% of wild boar (Sus scrofa ferus) in Extremadura (2000 publication)
12.8% of wolves (Canis lupus) in the northwestern region (Trichinella britovi, 1993 to 1999)

Outbreaks:
1. 51 outbreaks were reported during 1981 to 1987 – 24 (294 cases) due to wild boar, 18 (659 cases) due to domestic pork, and 12 unknown source.
2. 18 outbreaks were reported during 1988 to 1992.
3. 49 outbreaks were reported during 1990 to 2001 (75.5% due to wild boar, 14.3% domestic pork. Trichinella britovi was identified in 61.5%, and T. spiralis in 38.5%.
4. 32 outbreaks were reported during 1994 to 2003 – including 3 outbreaks (40 cases) in 2003.
5. Five outbreaks involving 86 cases were reported in Andalucia during 1984 to 1987 – including 4 from infected pork and one by from wild boar meat.

Notable outbreaks:
1982 to 1983 – An outbreak (452 cases) was caused by infested sausage prepared in Bdajoz.
1987 (publication year) – An outbreak was reported in Rioja Baja.
1992 to 1993 – An outbreak (19 cases) in Huerta del Marquesado was caused by contaminated pork.
1993 to 1994 – Outbreaks (2) in Cuenca and Teruel Provinces were associated with Trichinella britovi from wild boar sausages.
1995 (publication year) – An outbreak in Navarre was associated with consumption of home-prepared pork products.
1996 – An outbreak (42 cases) of Trichinella spiralis infection was traced to wild boar products in Iruela (Jaen).
1998 – An outbreak (140 cases) of infection by T. britovi from wild boar was reported in Grenada.
1998 – An outbreak (61 cases) was reported in Zaragoza.
1998 to 1999 – An outbreak (43 cases) in Germany was associated with raw sausage (“Mettwurst”) made from fresh pork imported from Spain.
2000 – An outbreak (38 cases, 0 fatal) of Trichinella britovi infection in Granada was ascribed to uninspected sausages.
2001 to 2002 – An outbreak (26 cases) of Trichinella britovi infection was reported in Caceres. Salami sausages were suspected as the reservoir.
2003 – An outbreak (33 cases) was reported in Burgos.
2007 – An outbreak (21 cases) of Trichinella britovi infection among persons in Spain and Sweden was related to Spanish wild boar sausage.
2009 (publication year) – An outbreak of trichinosis was reported in Salamanca Province.

References:
1. Berger SA. Infectious Diseases of Spain, 2011. 528 pp. Gideon e-book series, http://www.gideononline.com/ebooks/country/infectious-diseases-of-spain/
2. Berger SA. Infectious Diseases of the United States, 2011. 1,030 pp. Gideon e-book series, http://www.gideononline.com/ebooks/country/infectious-diseases-of-the-united-states/
3. Berger SA. Trichinosis: Global Status, 2011. 82 pp. Gideon e-book series, http://www.gideononline.com/ebooks/disease/trichinosis-global-status/

A recent outbreak in Madrid reminds us that Spain may well have the highest rate of legionellosis in the World. In the following graph, I’ve compared reported cases per 100,000 population for Spain and other regional countries with those of the United States.

67 specific outbreaks have been described in the World’s literature for the United States, as compared to 37 for Spain; however, the number of outbreaks per million population in Spain (0.80) is over 3.6-fold that for the United States (0.22).

The following chronology of legionellosis outbreaks in Spain is abstracted from the Gideon e-book series. [1,2] (primary references available on request)

1973 – An outbreak (89 cases, 3 fatal) was associated with a hotel in Benidorm.
1978 (publication year) – An outbreak (2 fatal cases) was associated with a hotel in Benidorm.
1983 – An outbreak (35 cases) in Valencia was related to contaminated shower heads and toilet tanks.
1984 (publication year) – An outbreak was reported in Los Castillejos.
1984 – An outbreak (32 cases) was reported among Dutch tourists at a hotel in Pineda de Mar (Barcelona region, Spain).
1988 – An outbreak (56 cases) was reported in Barcelona.
1992 (publication year) – An outbreak (6 cases) in a private apartment building in Zaragoza was associated with potable water.
1992 (publication year) – An outbreak was reported in a hospital in Badalona.
1993 – An outbreak (4 British tourists and 1 French tourist) was reported at a hotel in Spain.
1994 – An outbreak (20 cases) was reported in L’Espluga de Francoli, Tarragona.
1996 – An outbreak (260 cases, 197 hospitalized, 14 fatal) was reported in Madrid region (Alcala de Henares). This was the largest outbreak reported in Europe to date.
1996 – An outbreak (4 cases) was reported among British tourists at a hotel in Minorca.
1998 – An outbreak (3 cases, all fatal) was reported in a hospital in Zaragoza.
1999 – An outbreak (6 cases) was reported among foreign tourists to a spa in Cestona (Guipuzcoa Province).
1999 – An outbreak (7 cases, 1 fatal) was associated with a hotel outbreak in Benidorm.
2000 – An outbreak (70 cases, 2 fatal) was reported in Alcoy (Valencia region).
2000 – An outbreak (28 cases) was associated with a cooling tower in the region of a hospital in Vigo (Galicia).
2000 – An outbreak (54 cases, 17 hospitalized, 3 fatal) was reported in the “La Barceloneta” district of Barcelona.
2001 (publication year) – An outbreak (2 cases, both fatal) was reported among mechanics working on a cargo ship in the port of Barcelona.
2001 – An outbreak of 751 clinical cases (449 confirmed, 2 fatal) was reported in Santa Maria de Gracia (Murcia) – the world’s largest recorded outbreak to that time. The source of infection was an outdoor hospital cooling tower.
2001 – An outbreak (18 cases, 3 fatal) was reported from a hospital in Pamplona. A contaminated hot water system was implicated.
2002 – An outbreak (124 cases, 2 fatal) in Matara, Catalonia was related to a local cooling tower. 43 44 45
2003 – Outbreaks (25 total cases, 1 fatal) were reported in Valencia.
2003 – An outbreak (4 cases) was reported at a spa on Tenerife. An additional suspect case was reported in a Venezuelan visitor to the spa.
2004 – An outbreak (28 confirmed cases, 1 fatal) was reported at a hospital in Zaragoza. Contaminated cooling towers were implicated.
2004 – An outbreak (33 cases, 2 fatal) in Vallarca, Barcelona was caused by a contaminated air conditioning system at a private clinic.
2005 – An outbreak (19 cases, 3 fatal) was reported in Barcelona.
2005 – An outbreak (28 cases, including 21 foreigners – 0 fatal) was associated with a shopping center in Torrevieja.
2005 – An outbreak (55 cases, 3 fatal) was associated with a cooling tower in Catalonia.
2006 – An outbreak (146 cases, 0 fatal) in Pamplona was ascribed to contaminated cooling towers.
2006 – An outbreak (5 cases) was reported among ceramic workers in Castellon.
2006 – An outbreak (12 cases) in Catalonia was related to a contaminated mist machine.
2007 (publication year) – An outbreak of Legionnaires’ disease was reported among immunosuppressed patients at a cancer centre in Barcelona.
2007 to 2008 – An outbreak (3 cases) on a hospital surgical ward was associated with a contaminated oxygen humidifier.
2010 – An outbreak (16 cases) in Alcoy was related to a car-washing machine. This was the 16th outbreak in Alcoy since 1999.
2010 – An outbreak (43 cases) of Pontiac fever was reported in Barcelona.
2009 – An outbreak (11 cases, 1 fatal) in Alcoy was related to exposure to the water tank of a milling machine used in street asphalt repaving.

References:
1. Berger SA. Infectious Diseases of Spain, 511 pp, 2,036 refs. 2010, Gideon e-book series. http://www.gideononline.com/ebooks/country/infectious-diseases-of-spain/
2. Berger SA. Legionellosis: Global Status, 82 pp, 751 refs. 2010, Gideon e-book series. http://www.gideononline.com/ebooks/disease/legionellosis-global-status/

A recent case of autochthonous infection in Huesca Province highlights the fact that malaria rates in Spain have increased dramatically since the 1960′s. See graph

Graph notes:
1. 461 cases were reported during 1973 to 1982; 1,707 during 1985 to 1994.
2. Plasmodium falciparum accounted for 59.6% of cases reported during 1989 to 1995, with a case/fatality rate of 1.91% among patients infected with this species.
3. P. falciparum accounted for 62.6% of cases reported during 1996 to 1999.
4. No cases of ‘airport malaria’ were reported during 1994 to 1995.
Individual years:
1994 – 69.02% imported from Africa. 115 of these reported from Madrid and 74 from Cataluna.
1995 – 228 from Africa. 89 were from Equatorial Guinea).
1996 – 117 from Madrid and Cataluna. 143 from Africa (51 from Equatorial Guinea).
1997 – 181 from Madrid and Cataluna. 208 from Africa (61 from Equatorial Guinea).
1998 – 219 from Madrid and Cataluna. 271 from Africa (104 from Equatorial Guinea).
1999 – 219 from Madrid and Cataluna. 229 from Africa (65 from Equatorial Guinea).

The following background data are abstracted from references 1 and 2.

Malaria was extremely common in Spain during the first decades of the twentieth century, with 293,000 cases and 1,278 deaths reported during the late 1930′s to early 1940′s. The last confirmed indigenous cases were reported during the 1950′s, and Spain was certified “malaria-free” by WHO in September 1964.

Autochthonous or Introduced malaria:
1978 – A case of introduced malaria was reported (a nurse who had been in contact with a malaria patient).
1984 – An outbreak of 4 cases was reported among injecting drug users in Madrid in 1984. A similar outbreak (2 IDU in Cataluna) was reported in 1986.
1987 – A case of transfusion-related malaria was reported in Valencia.
1991 – An outbreak (43 cases from transfused blood and 11 from plasma) of ‘introduced malaria’ was reported.
1998 – Spain’s last case of introduced malaria (from Mauritania) was reported in the Canary Islands in 1998.

Prevalence surveys:
3.8% of asymptomatic immigrants referred to a tropical medical unit (Madrid, 1989 to 2008)

Vectors:
The local potential vectors are Anopheles atroparvus (throughout) and An. messeae (in the north).
- An. labranchiae, once a common vector, is not longer found in Spain.

References:
1. Berger SA. Infectious Diseases of Spain, 511 pp, 2,036 refs. Gideon e-book series, 2010.
2. Berger SA. Malaria: Global Status, 370 pp, 1,609 refs. Gideon e-book series, 2010.

A recent outbreak in Alcoy reminds us that rates of legionellosis have been increasing in Spain. The following background data are abstracted from the GIDEON e-book series. [1,2]

Graph 1 summarizes disease incidence and rates per 100,000 population.

Graph Notes:
1. 47 cases were reported in the Balearic Islands during 2001 to 2003.
2. 460 cases were reported among Spanish tourists during 2002 to 2006; 30 in 2005; 73 in 2006.
Individual years:
1993 – Included 57 cases in Cataluna
2003 – 5.82 per 100,000 in the Balearic Islands

As seen in Graph 2, this increase has also affected tourists in Spain.

Graph Notes:
1. 281 cases were acquired by foreign tourists in Spain during 1987 to 1995 – 67% of these from Great Britain. 37% of these were acquired in the Balearic Islands.
2. 627 cases were acquired by foreign tourists in Spain during 1989 to 2001.
3. 6,411 cases of legionellosis were reported during 1999 to 2004 – 565 (9%) involving Spanish travelers, and 426 involving foreign travelers in Spain.
4. 73 travel-associated cases were reported in 2006; 68 in 2007.
Individual years:
2003 – Included nine Spanish citizens touring within Spain.

Legionellosis accounts for 3% of community-acquired pneumonia in Palma de Mallorca (1992 to 1994)

Outbreaks – an overview:
- 1989 to 1998 – 55 outbreaks of legionellosis were reported – 36 of these associated with tourism, 11 nosocomial and 8 community-acquired.
- A single hotel in Benidorm was implicated in the infection of 3 tourists in 1989, 1 in 1990, 2 in 1995, 1 in 1996; 3 in 1997; 8 (1 fatal) in 1998.
- 1990 to 1991 – 54 outbreaks involving 805 cases (and additional 1,358 sporadic cases) were reported.
- 1990 to 2004 – 118 outbreaks involving 690 patients were reported in Catalonia – 35.6% involving water towers, and 14.4% involving water distribution systems in public buildings.
- 1999 to 2001 – Four outbreaks affected over 160 people in Alcoy.
- 2000 – Seven outbreaks were reported – 4 of these nosocomial. An additional 4 clusters were reported among tourists to Spain.
- 2000 – Girona reported 32 cases (3 fatal); Barcelona 48 (1 fatal); Vigo 30 (4 fatal) and Alcala de Henares 249 (11 fatal).
- 2001 to 2003 – 135 cases (10 fatal) in 46 clusters were acquired by European travelers to Spain, including 85 in 2002
- 1999 to 2003 – Eight outbreaks (approximately 300 cases) were reported in Alcoy, Alicante.
- 2003 – 55 outbreaks (247 cases) were reported.

Notable outbreaks:
1973 – An outbreak (89 cases, 3 fatal) was associated with a hotel in Benidorm.
1978 (publication year) – An outbreak (2 fatal cases) was associated with a hotel in Benidorm.
1983 – An outbreak (35 cases) in Valencia was related to contaminated shower heads and toilet tanks.
1984 (publication year) – An outbreak was reported in Los Castillejos.
1984 – An outbreak (32 cases) was reported among Dutch tourists at a hotel in Pineda de Mar (Barcelona region, Spain).
1988 – An outbreak (56 cases) was reported in Barcelona.
1992 (publication year) – An outbreak (6 cases) in a private apartment building in Zaragoza was associated with potable water.
1992 (publication year) – An outbreak was reported in a hospital in Badalona.
1993 – An outbreak (4 British tourists and 1 French tourist) was reported at a hotel in Spain.
1994 – An outbreak (20 cases) was reported in L’Espluga de Francoli, Tarragona.
1996 – An outbreak (260 cases, 197 hospitalized, 14 fatal) was reported in Madrid region (Alcala de Henares). This was the largest outbreak reported in Europe to date.
1996 – An outbreak (4 cases) was reported among British tourists at a hotel in Minorca.
1998 – An outbreak (3 cases, all fatal) was reported in a hospital in Zaragoza.
1999 – An outbreak (6 cases) was reported among foreign tourists to a spa in Cestona (Guipuzcoa Province).
1999 – An outbreak (7 cases, 1 fatal) was associated with a hotel outbreak in Benidorm.
2000 – An outbreak (70 cases, 2 fatal) was reported in Alcoy (Valencia region).
2000 – An outbreak (28 cases) was associated with a cooling tower in the region of a hospital in Vigo (Galicia).
2000 – An outbreak (54 cases, 17 hospitalized, 3 fatal) was reported in the “La Barceloneta” district of Barcelona.
2001 (publication year) – An outbreak (2 cases, both fatal) was reported among mechanics working on a cargo ship in the port of Barcelona.
2001 – An outbreak of 751 clinical cases (449 confirmed, 2 fatal) was reported in Santa Maria de Gracia (Murcia) – the world’s largest recorded outbreak to that time. The source of infection was an outdoor hospital cooling tower.
2001 – An outbreak (18 cases, 3 fatal) was reported from a hospital in Pamplona. A contaminated hot water system was implicated.
2002 – An outbreak (124 cases, 2 fatal) in Matara, Catalonia was related to a local cooling tower.
2003 – Outbreaks (25 total cases, 1 fatal) were reported in Valencia.
2003 – An outbreak (4 cases) was reported at a spa on Tenerife. An additional suspect case was reported in a Venezuelan visitor to the spa.
2004 – An outbreak (28 confirmed cases, 1 fatal) was reported at a hospital in Zaragoza. Contaminated cooling towers were implicated.
2004 – An outbreak (33 cases, 2 fatal) in Vallarca, Barcelona was caused by a contaminated air conditioning system at a private clinic.
2005 – An outbreak (19 cases, 3 fatal) was reported in Barcelona.
2005 – An outbreak (28 cases, including 21 foreigners – 0 fatal) was associated with a shopping center in Torrevieja.
2005 – An outbreak (55 cases, 3 fatal) was associated with a cooling tower in Catalonia.
2006 – An outbreak (146 cases, 0 fatal) in Pamplona was ascribed to contaminated cooling towers.
2006 – An outbreak (5 cases) was reported among ceramic workers in Castellon.
2006 – An outbreak (12 cases) in Catalonia was related to a contaminated mist machine.
2007 (publication year) – An outbreak of Legionnaires’ disease was reported among immunosuppressed patients at a cancer centre in Barcelona.
2007 to 2008 – An outbreak (3 cases) on a hospital surgical ward was associated with a contaminated oxygen humidifier.

References:
1. Berger SA. Infectious Diseases of Spain, 516 pp. Gideon Informatics, Inc. 2010, http://www.gideononline.com/ebooks/country/infectious-diseases-of-spain/
2. Berger SA. Legionellosis: Global Status, 84 pp. Gideon Informatics, Inc. 2010, http://www.gideononline.com/ebooks/disease/legionellosis-global-status/

Although leishmaniasis has generated increasing concern in Spain during recent years, the incidence of reported cases has changed little during the past 25 years. The following data are abstracted from the GIDEON e-book series [1,2].

Time and Place:
Visceral leishmaniasis is most common in the southern region.
- Seroprevalence among dogs in this region is lowest during April, peaking during October.
- A restricted focus has been identified in the Piorat region of northeastern Spain.
- A single autochthonous case has been reported from Minorca.

Graph Notes:
1. 1,180 hospitalizations were reported for leishmaniasis during 1999 to 2003 (0.4 per 100,000 population).
2. 11 cases (0 fatal) were identified among immunocompetent children in southern Madrid during 1994 to 2007.
3. 60 deaths were ascribed to leishmaniasis during 1980 to 1994.
4. In 2005, three cases were reported among Romanian workers returning from Spain.

Leishmaniasis and HIV infection:
- 450 AIDS/Leishmania coinfections were reported nationwide during 1990 to 1995 (52.4% of the world’s total coinfections); 412 during 1996 to 1998; 1,099 as of 2001.
- 835 cases of HIV-Leishmania coinfection were reported during January 1990 to June 1998; 412 during January 1996 to June 1998; 1,099 during January 1990 to January 2001; 130 during January 2001 to December 2006.
- Spain accounted for 58% of all such coinfections in southwestern Europe during 1990 to 1998.
- 2.49% of AIDS patients in the Madrid region are coinfected with visceral leishmaniasis.
- 228 episodes of visceral leishmaniasis were diagnosed in 155 HIV-infected patients in Valencia and Murcia during 1988 to 2001.

Transmission through sharing of needles by injecting drug abusers has been reported.
- Approximately 30% of IVDA in southern Spain are seropositive.
- Evidence for Leishmania is found in 52% of discarded syringes collected in southern Madrid (1998) and 34% from southwestern Madrid (2000 to 2001).

Leishmania infantum has been identified in some cases of cutaneous and mucosal leishmaniasis.

Prevalence surveys:
2.4% of asymptomatic blood donors in Elvissa (Belearic Islands) have been found to have cryptic infection by ELISA – 7.6% by Western blot (2004 publication)
20.5% of wolves (Canis lupus), 14.1% of foxes (Vulpes vulpes), 28.6% of Egyptian mongooses (Herpestes ichneumon), 1 of 4 genets (Geneta geneta), and 1 of 4 Iberian lynxes (Lynx pardinus) (2008 publication)
29.4% of dogs in the Barcelona region (PCR, 2009 publication)
19.6% of seronegative blood samples in a canine blood bank. (Leishmanial DNA, Barcelona, 2008 publication)

Seroprevalence surveys:
3.1% of blood donors from the Balearic Islands. (Majorca, Formentera, and Minorca, 2008 publication)
4.9% of the general population in Castilla Leon, and 64.0% of HIV-positive patients (1996)
11.5% of children and 52.8% of adults in Alicante, southeastern region are skin test-positive (1997 to 1998)
5.25% of dogs in the Madrid area
7.8% of stray dogs in the Madrid region (1996 to 2006)
13% of dogs on Mallorca are infected; 3.7% in northwestern Spain (2004 publication)
30% of dogs in northeastern Spain (2006 publication)
22% of dogs in Crevillente town, Alicante (1999)
13.0% of dogs in the Alpujarras region of southeastern Spain – with highest rates in larger, older dogs which live outdoors (2006)
8.1% of dogs in the Madrid region (2006 to 2007)
5.3% of shelter dogs in central Spain (2010 publication)
3% of cats in Barcelona (2007 publication)
1.29% of cats in Madrid (2005 to 2006)
6.29% of cats in the northeastern Iberian Peninsula and Balearic Islands (2007 publication)

Leishmania infantum has been identified in captive wolves (Canis lupus) in northern Spain (2008 publication)

Vectors:
The vectors in Spain are Phlebotomus (Larroussius) ariasi and Ph. (La.) perniciosus.

References:
1. Berger SA. Infectious Diseases of Spain. http://www.gideononline.com/ebooks/country/infectious-diseases-of-spain/ , 516 pp. 2010, Gideon Informatics, Inc.
2. Berger SA. Visceral Leishmaniasis: Global Status. http://www.gideononline.com/ebooks/disease/visceral-leishmaniasis-global-status/ , 84 pp. 2010, Gideon Informatics, Inc.

A variety of spotted fever group Rickettsiae are reported in Spain.

The incidence of Mediterranean spotted fever cases has decreased in recent years, from 870 cases in 1989, to 234 in 2003. 77.76% of cases are reported from Andalucia, Castilla La Mancha, Castilla y Leon and Cataluna, with most occurring during July through October. 38 fatal cases were reported during 1980 to 1994.

Seroprevalence surveys:
8% of healthy persons and 26.1% of dogs in Catalonia – highest rates in seimrural areas (1997)
8.7% of persons in southern Spain (2002)
3.4% of persons in southern Spain (Bar29 infection, 2006 publication)
3.7% of persons in Catalonia (Rickettsia slovaka, 2008 publication)
56.4% of dogs in northeastern Spain (2006 publication)
24.6% of dogs in Ourense and Pontevedra (northwestern Spain, 2008 publication)
44% of cats in northeastern Spain (2006 publication)

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