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1.
Rev Bras Epidemiol ; 23: e200095, 2020.
Article in Portuguese, English | MEDLINE | ID: covidwho-836012

ABSTRACT

OBJECTIVE: To assess, through space-time analyses, whether the income inequality of the Federative Units (FUs) in Brazil can be associated with the risk of infection and death by COVID-19. METHODS: This was an ecological study, based on secondary data on incidence and mortality rates for COVID-19. Data were analyzed at the state level, having the Gini coefficient as the main independent variable. Records of twelve days were used, spaced one week each, between April 21th and June 7th, 2020. The weekly variation in the rates was calculated through Prais-Winsten regression, aiming at measuring the evolution of the pandemic in each FU. Spearman's correlation test was used to assess correlation between the rates and their weekly evolution and the independent variables. Lastly, a spatial dependence diagnosis was conducted, and a Spatial Regression lag model was used when applicable. RESULTS: Incidence and mortality rates of COVID-19 increased in all Brazilian FUs, being more pronounced among those with greater economic inequality. Association between Gini coefficient and COVID-19 incidence and mortality rates remained even when demographic and spatial aspects were taken into account. CONCLUSION: Income inequality can play an important role in the impact of COVID-19 on the Brazilian territory, through absolute and contextual effects. Structural policies to reduce inequality are essential to face this and future health crises in Brazil.


Subject(s)
Coronavirus Infections/epidemiology , Health Status Disparities , Pandemics , Pneumonia, Viral/epidemiology , Brazil/epidemiology , Coronavirus Infections/mortality , Humans , Pneumonia, Viral/mortality , Risk Assessment , Socioeconomic Factors
5.
Int J Equity Health ; 19(1): 170, 2020 10 01.
Article in English | MEDLINE | ID: covidwho-811671

ABSTRACT

With the threat of coronavirus disease 2019 (Covid-19) enduring in the United States, effectively and equitably implementing testing, tracing, and self-isolation as key prevention and detection strategies remain critical to safely re-opening communities. As testing and tracing capacities increase, frameworks are needed to inform design and delivery to ensure their effective implementation and equitable distribution, and to strengthen community engagement in slowing and eventually stopping Covid-19 transmission. In this commentary, we highlight opportunities for integrating implementation research into planned and employed strategies in the United States to accelerate reach and effectiveness of interventions to more safely relax social distancing policies and open economies, schools, and other institutions. Implementation strategies, such as adapting evidence-based interventions based on contextual factors, promoting community engagement, and providing data audit and feedback on implementation outcomes, can support the translation of policies on testing, tracing, social distancing, and public mask use into reality. These data can demonstrate how interventions are put into practice and where adaptation in policy or practice is needed to respond to the needs of specific communities and socially vulnerable populations. Incorporating implementation research into Covid-19 policy design and translation into practice is urgently needed to mitigate the worsening health inequities in the pandemic toll and response. Applying rigorous implementation research frameworks and evaluation systems to the implementation of evidence-based interventions which are adapted to contextual factors can promote effective and equitable pandemic response and accelerate learning both among local stakeholders as well as between states to further inform their varied experiences and responses to the pandemic.


Subject(s)
Coronavirus Infections/epidemiology , Coronavirus Infections/prevention & control , Health Status Disparities , Implementation Science , Pandemics/prevention & control , Pneumonia, Viral/epidemiology , Pneumonia, Viral/prevention & control , Humans , Public Policy , United States/epidemiology
6.
J Am Board Fam Med ; 33(5): 645-649, 2020.
Article in English | MEDLINE | ID: covidwho-807208

ABSTRACT

The COVID-19 outbreak is a stark reminder of the ongoing challenge of emerging and reemerging disease, the human cost of pandemics and the need for robust research.1 For primary care, the advent of COVID-19 has forced an unprecedented wave of practice change. In turn, Practice-Based Research Networks (PBRNs) must rapidly pivot to address the changing environment and the critical challenges faced by primary care. The pandemic has also impacted the ability of PBRNs to deploy traditional research methods such as face-to-face patient and provider interactions, practice facilitation, and stakeholder engagement. Providers need more relevant, patient-centered evidence and the skills to effect change. These skills will become more important than ever as primary care practices evolve in response to the current COVID-19 pandemic and the disparities in health outcomes highlighted by COVID-19 and the global Black Lives Matter social movement for justice. Throughout this issue, authors detail the work conducted by PBRNs that demonstrate many of these evolving concepts. Articles explore how PBRNs can evaluate COVID-19 in primary care, the role of PBRNs in quality improvement, stakeholder engagement, prevention and chronic care management, and patient safety in primary care.


Subject(s)
Betacoronavirus , Community Networks/trends , Coronavirus Infections , Health Services Research/trends , Pandemics , Pneumonia, Viral , Primary Health Care/trends , Community Networks/organization & administration , Health Services Research/methods , Health Services Research/organization & administration , Health Status Disparities , Healthcare Disparities , Humans , Primary Health Care/methods , Primary Health Care/organization & administration , Research Design , Stakeholder Participation , United States
7.
BMJ Open ; 10(9): e039749, 2020 09 29.
Article in English | MEDLINE | ID: covidwho-808388

ABSTRACT

OBJECTIVES: The growth of COVID-19 infections in England raises questions about system vulnerability. Several factors that vary across geographies, such as age, existing disease prevalence, medical resource availability and deprivation, can trigger adverse effects on the National Health System during a pandemic. In this paper, we present data on these factors and combine them to create an index to show which areas are more exposed. This technique can help policy makers to moderate the impact of similar pandemics. DESIGN: We combine several sources of data, which describe specific risk factors linked with the outbreak of a respiratory pathogen, that could leave local areas vulnerable to the harmful consequences of large-scale outbreaks of contagious diseases. We combine these measures to generate an index of community-level vulnerability. SETTING: 91 Clinical Commissioning Groups (CCGs) in England. MAIN OUTCOME MEASURES: We merge 15 measures spatially to generate an index of community-level vulnerability. These measures cover prevalence rates of high-risk diseases; proxies for the at-risk population density; availability of staff and quality of healthcare facilities. RESULTS: We find that 80% of CCGs that score in the highest quartile of vulnerability are located in the North of England (24 out of 30). Here, vulnerability stems from a faster rate of population ageing and from the widespread presence of underlying at-risk diseases. These same areas, especially the North-East Coast areas of Lancashire, also appear vulnerable to adverse shocks to healthcare supply due to tighter labour markets for healthcare personnel. Importantly, our index correlates with a measure of social deprivation, indicating that these communities suffer from long-standing lack of economic opportunities and are characterised by low public and private resource endowments. CONCLUSIONS: Evidence-based policy is crucial to mitigate the health impact of pandemics such as COVID-19. While current attention focuses on curbing rates of contagion, we introduce a vulnerability index combining data that can help policy makers identify the most vulnerable communities. We find that this index is positively correlated with COVID-19 deaths and it can thus be used to guide targeted capacity building. These results suggest that a stronger focus on deprived and vulnerable communities is needed to tackle future threats from emerging and re-emerging infectious disease.


Subject(s)
Communicable Disease Control , Coronavirus Infections , Disease Transmission, Infectious/prevention & control , Health Resources/supply & distribution , Health Services Accessibility/standards , Pandemics , Pneumonia, Viral , Betacoronavirus , Communicable Disease Control/methods , Communicable Disease Control/organization & administration , Coronavirus Infections/epidemiology , Coronavirus Infections/prevention & control , Coronavirus Infections/transmission , England/epidemiology , Health Status Disparities , Humans , Needs Assessment , Pandemics/prevention & control , Pneumonia, Viral/epidemiology , Pneumonia, Viral/prevention & control , Pneumonia, Viral/transmission , Prevalence , Public Health/methods , Public Health/trends , Quality Improvement/organization & administration , Risk Factors , Spatial Analysis
8.
N Z Med J ; 133(1521): 28-39, 2020 09 04.
Article in English | MEDLINE | ID: covidwho-807838

ABSTRACT

AIMS: There is limited evidence as to how clinical outcomes of COVID-19 including fatality rates may vary by ethnicity. We aim to estimate inequities in infection fatality rates (IFR) in New Zealand by ethnicity. METHODS: We combine existing demographic and health data for ethnic groups in New Zealand with international data on COVID-19 IFR for different age groups. We adjust age-specific IFRs for differences in unmet healthcare need, and comorbidities by ethnicity. We also adjust for life expectancy reflecting evidence that COVID-19 amplifies the existing mortality risk of different groups. RESULTS: The IFR for Maori is estimated to be 50% higher than that of non-Maori, and could be even higher depending on the relative contributions of age and underlying health conditions to mortality risk. CONCLUSIONS: There are likely to be significant inequities in the health burden from COVID-19 in New Zealand by ethnicity. These will be exacerbated by racism within the healthcare system and other inequities not reflected in official data. Highest risk communities include those with elderly populations, and Maori and Pacific communities. These factors should be included in future disease incidence and impact modelling.


Subject(s)
Betacoronavirus , Coronavirus Infections/ethnology , Ethnic Groups/statistics & numerical data , Health Status Disparities , Life Expectancy/ethnology , Oceanic Ancestry Group/statistics & numerical data , Pneumonia, Viral/ethnology , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Coronavirus Infections/mortality , Female , Humans , Infant , Infant, Newborn , Male , Middle Aged , New Zealand , Pandemics , Pneumonia, Viral/mortality , Survival Rate , Young Adult
10.
Cad Saude Publica ; 36(9): e00150120, 2020.
Article in English, Portuguese | MEDLINE | ID: covidwho-796853

ABSTRACT

COVID-19 incidence and mortality in countries with heavy social inequalities differ in population terms. In countries like Brazil with colonial histories and traditions, the social markers of differences are heavily anchored in social and racial demarcation, and the political and social dynamics and processes based on structural racism act on this demarcation. The pandemic's actual profile in Brazil clashes with narratives according to which COVID-19 is a democratic pandemic, an argument aligned with the rhetoric of racial democracy that represents a powerful strategy aimed at maintaining the subaltern place of racialized populations such as indigenous peoples and blacks, as a product of modern coloniality. This essay focuses on the pandemic's profile in the Brazilian black population, in dialogue with decolonial contributions and critical readings of racism. The authors discuss government responses and COVID-19 indicators according to race/color, demonstrating the maintenance of historical storylines that continue to threaten black lives. The article also discusses the importance of local resistance movements, organized in the favelas, precarious urban spaces underserved by the State and occupied by black Brazilians.


Subject(s)
Continental Population Groups/ethnology , Coronavirus Infections/epidemiology , Health Status Disparities , Healthcare Disparities , Pneumonia, Viral/epidemiology , Racism , Betacoronavirus , Brazil , Cause of Death , Coronavirus Infections/mortality , Humans , Pandemics , Pneumonia, Viral/mortality , Socioeconomic Factors
12.
JAMA Netw Open ; 3(9): e2021892, 2020 09 01.
Article in English | MEDLINE | ID: covidwho-795041

ABSTRACT

Importance: Initial public health data show that Black race may be a risk factor for worse outcomes of coronavirus disease 2019 (COVID-19). Objective: To characterize the association of race with incidence and outcomes of COVID-19, while controlling for age, sex, socioeconomic status, and comorbidities. Design, Setting, and Participants: This cross-sectional study included 2595 consecutive adults tested for COVID-19 from March 12 to March 31, 2020, at Froedtert Health and Medical College of Wisconsin (Milwaukee), the largest academic system in Wisconsin, with 879 inpatient beds (of which 128 are intensive care unit beds). Exposures: Race (Black vs White, Native Hawaiian or Pacific Islander, Native American or Alaska Native, Asian, or unknown). Main Outcomes and Measures: Main outcomes included COVID-19 positivity, hospitalization, intensive care unit admission, mechanical ventilation, and death. Additional independent variables measured and tested included socioeconomic status, sex, and comorbidities. Reverse transcription polymerase chain reaction assay was used to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Results: A total of 2595 patients were included. The mean (SD) age was 53.8 (17.5) years, 978 (37.7%) were men, and 785 (30.2%) were African American patients. Of the 369 patients (14.2%) who tested positive for COVID-19, 170 (46.1%) were men, 148 (40.1%) were aged 60 years or older, and 218 (59.1%) were African American individuals. Positive tests were associated with Black race (odds ratio [OR], 5.37; 95% CI, 3.94-7.29; P = .001), male sex (OR, 1.55; 95% CI, 1.21-2.00; P = .001), and age 60 years or older (OR, 2.04; 95% CI, 1.53-2.73; P = .001). Zip code of residence explained 79% of the overall variance in COVID-19 positivity in the cohort (ρ = 0.79; 95% CI, 0.58-0.91). Adjusting for zip code of residence, Black race (OR, 1.85; 95% CI, 1.00-3.65; P = .04) and poverty (OR, 3.84; 95% CI, 1.20-12.30; P = .02) were associated with hospitalization. Poverty (OR, 3.58; 95% CI, 1.08-11.80; P = .04) but not Black race (OR, 1.52; 95% CI, 0.75-3.07; P = .24) was associated with intensive care unit admission. Overall, 20 (17.2%) deaths associated with COVID-19 were reported. Shortness of breath at presentation (OR, 10.67; 95% CI, 1.52-25.54; P = .02), higher body mass index (OR per unit of body mass index, 1.19; 95% CI, 1.05-1.35; P = .006), and age 60 years or older (OR, 22.79; 95% CI, 3.38-53.81; P = .001) were associated with an increased likelihood of death. Conclusions and Relevance: In this cross-sectional study of adults tested for COVID-19 in a large midwestern academic health system, COVID-19 positivity was associated with Black race. Among patients with COVID-19, both race and poverty were associated with higher risk of hospitalization, but only poverty was associated with higher risk of intensive care unit admission. These findings can be helpful in targeting mitigation strategies for racial disparities in the incidence and outcomes of COVID-19.


Subject(s)
African Americans , Coronavirus Infections/ethnology , Health Status Disparities , Hospitalization , Intensive Care Units , Pneumonia, Viral/ethnology , Adult , Aged , Betacoronavirus , Body Mass Index , Cohort Studies , Comorbidity , Coronavirus Infections/complications , Coronavirus Infections/mortality , Coronavirus Infections/virology , Cross-Sectional Studies , Dyspnea/epidemiology , Dyspnea/etiology , Female , Humans , Incidence , Male , Middle Aged , Minority Groups , Odds Ratio , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/mortality , Pneumonia, Viral/virology , Poverty , Respiration, Artificial , Wisconsin/epidemiology
13.
West J Emerg Med ; 21(5): 1048-1053, 2020 Aug 17.
Article in English | MEDLINE | ID: covidwho-793418

ABSTRACT

INTRODUCTION: The unfolding COVID-19 pandemic has predictably followed the familiar contours of well established socioeconomic health inequities, exposing and often amplifying preexisting disparities. People living in homeless shelters are at higher risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) compared to the general population. The purpose of this study was to identify shelter characteristics that may be associated with higher transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: We conducted a cross-sectional assessment of five congregate shelters in Rhode Island. Shelter residents 18 years old and older were tested for SARS-CoV-2 from April 19-April 24, 2020. At time of testing, we collected participant characteristics, symptomatology, and vital signs. Shelter characteristics and infection control strategies were collected through a structured phone questionnaire with shelter administrators. RESULTS: A total of 299 shelter residents (99%, 299/302) participated. Thirty-five (11.7%) tested positive for SARS-CoV-2. Shelter-level prevalence ranged from zero to 35%. Symptom prevalence did not vary by test result. Shelters with positive cases of SARS-CoV-2 were in more densely populated areas, had more transient resident populations, and instituted fewer physical distancing practices compared to shelters with no cases. CONCLUSION: SARS-CoV-2 prevalence varies with shelter characteristics but not individual symptoms. Policies that promote resident stability and physical distancing may help reduce SARS-CoV-2 transmission. Symptom screening alone is insufficient to prevent SARS-CoV-2 transmission. Frequent universal testing and congregate housing alternatives that promote stability may help reduce spread of infection.


Subject(s)
Betacoronavirus , Coronavirus Infections/epidemiology , Health Status Disparities , Homeless Persons/statistics & numerical data , Housing/statistics & numerical data , Pneumonia, Viral/epidemiology , Adolescent , Adult , Aged , Aged, 80 and over , Coronavirus Infections/diagnosis , Coronavirus Infections/prevention & control , Coronavirus Infections/transmission , Cross-Sectional Studies , Female , Health Policy , Health Surveys , Humans , Infection Control/methods , Male , Middle Aged , Pandemics/prevention & control , Pneumonia, Viral/diagnosis , Pneumonia, Viral/prevention & control , Pneumonia, Viral/transmission , Prevalence , Rhode Island/epidemiology , Young Adult
14.
MMWR Morb Mortal Wkly Rep ; 69(38): 1369-1373, 2020 Sep 25.
Article in English | MEDLINE | ID: covidwho-793106

ABSTRACT

Coronavirus disease 2019 (COVID-19) has had a substantial impact on racial and ethnic minority populations and essential workers in the United States, but the role of geographic social and economic inequities (i.e., deprivation) in these disparities has not been examined (1,2). As of July 9, 2020, Utah had reported 27,356 confirmed COVID-19 cases. To better understand how area-level deprivation might reinforce ethnic, racial, and workplace-based COVID-19 inequities (3), the Utah Department of Health (UDOH) analyzed confirmed cases of infection with SARS-CoV-2 (the virus that causes COVID-19), COVID-19 hospitalizations, and SARS-CoV-2 testing rates in relation to deprivation as measured by Utah's Health Improvement Index (HII) (4). Age-weighted odds ratios (weighted ORs) were calculated by weighting rates for four age groups (≤24, 25-44, 45-64, and ≥65 years) to a 2000 U.S. Census age-standardized population. Odds of infection increased with level of deprivation and were two times greater in high-deprivation areas (weighted OR = 2.08; 95% confidence interval [CI] = 1.99-2.17) and three times greater (weighted OR = 3.11; 95% CI = 2.98-3.24) in very high-deprivation areas, compared with those in very low-deprivation areas. Odds of hospitalization and testing also increased with deprivation, but to a lesser extent. Local jurisdictions should use measures of deprivation and other social determinants of health to enhance transmission reduction strategies (e.g., increasing availability and accessibility of SARS-CoV-2 testing and distributing prevention guidance) to areas with greatest need. These strategies might include increasing availability and accessibility of SARS-CoV-2 testing, contact tracing, isolation options, preventive care, disease management, and prevention guidance to facilities (e.g., clinics, community centers, and businesses) in areas with high levels of deprivation.


Subject(s)
Clinical Laboratory Techniques/statistics & numerical data , Coronavirus Infections/epidemiology , Coronavirus Infections/prevention & control , Health Status Disparities , Healthcare Disparities/statistics & numerical data , Hospitalization/statistics & numerical data , Pandemics/prevention & control , Pneumonia, Viral/epidemiology , Pneumonia, Viral/prevention & control , Poverty Areas , Adult , Aged , Coronavirus Infections/diagnosis , Humans , Incidence , Middle Aged , Risk Factors , Utah/epidemiology , Young Adult
16.
Cad Saude Publica ; 36(9): e00150120, 2020.
Article in English, Portuguese | MEDLINE | ID: covidwho-788948

ABSTRACT

COVID-19 incidence and mortality in countries with heavy social inequalities differ in population terms. In countries like Brazil with colonial histories and traditions, the social markers of differences are heavily anchored in social and racial demarcation, and the political and social dynamics and processes based on structural racism act on this demarcation. The pandemic's actual profile in Brazil clashes with narratives according to which COVID-19 is a democratic pandemic, an argument aligned with the rhetoric of racial democracy that represents a powerful strategy aimed at maintaining the subaltern place of racialized populations such as indigenous peoples and blacks, as a product of modern coloniality. This essay focuses on the pandemic's profile in the Brazilian black population, in dialogue with decolonial contributions and critical readings of racism. The authors discuss government responses and COVID-19 indicators according to race/color, demonstrating the maintenance of historical storylines that continue to threaten black lives. The article also discusses the importance of local resistance movements, organized in the favelas, precarious urban spaces underserved by the State and occupied by black Brazilians.


Subject(s)
Continental Population Groups/ethnology , Coronavirus Infections/epidemiology , Health Status Disparities , Healthcare Disparities , Pneumonia, Viral/epidemiology , Racism , Betacoronavirus , Brazil , Cause of Death , Coronavirus Infections/mortality , Humans , Pandemics , Pneumonia, Viral/mortality , Socioeconomic Factors
18.
Fam Process ; 59(3): 832-846, 2020 09.
Article in English | MEDLINE | ID: covidwho-787776

ABSTRACT

The COVID-19 pandemic brings to the forefront the complex interconnected dilemmas of globalization, health equity, economic security, environmental justice, and collective trauma, severely impacting the marginalized and people of color in the United States. This lack of access to and the quality of healthcare, affordable housing, and lack of financial resources also continue to have a more significant impact on documented and undocumented immigrants. This paper aims at examining these critical issues and developing a framework for family therapists to address these challenges by focusing on four interrelated dimensions: cultural values, social determinants of health, collective trauma, and the ethical and moral responsibility of family therapists. Given the fact that family therapists may unwittingly function as the best ally of an economic and political system that perpetuates institutionalized racism and class discrimination, we need to utilize a set of principles, values, and practices that are not just palliative or after the fact but bring forth into the psychotherapeutic and policy work a politics of care. Therefore, a strong call to promote and advocate for the broader continuum of health and critical thinking preparing professionals to meet the challenges of health equity, as well as economic and environmental justice, is needed. The issues discussed in this paper are specific to the United States despite their relevance to family therapy as a field. We are mindful not to generalize the United States' reality to the rest of the world, recognizing that issues discussed in this paper could potentially contribute to international discourse.


Subject(s)
Family Therapy/ethics , Health Status Disparities , Pandemics/ethics , Politics , Racism/ethics , Betacoronavirus , Climate Change , Coronavirus Infections/ethnology , Coronavirus Infections/psychology , Healthcare Disparities , Humans , Morals , Pneumonia, Viral/ethnology , Pneumonia, Viral/psychology , Racism/psychology , Social Determinants of Health , Social Marginalization , Social Values , United States/epidemiology
20.
Rev Esp Salud Publica ; 942020 09 16.
Article in Spanish | MEDLINE | ID: covidwho-774689

ABSTRACT

OBJECTIVE: Social determinants and health inequalities have a huge impact on health of populations. It is important to study their role in the management of the Covid-19 epidemic, especially in cities, as certain variables like the number of tests and the access to health system cannot be assumed as equal. The aim of this work was to determine the relation of social determinants in the incidence of Covid-19 in the city of Barcelona. METHODS: An observational retrospective ecological study was performed, with the neighbourhood as the population unit, based on data of cumulative incidence published at May 14th, 2020 by the Public Health Agency of Barcelona. Covid-19 incidence disparities depending on the income of the neighbourhoods, the Pearson linear correlation of the variables selected (age, sex, net density, immigrants, comorbidities, smokers, Body Mass Index [BMI] and Available Income per Family Index [AIFI]) with the incidence and the correlation with a multivariant Generalized Linear Model (GLM) were estimated. RESULTS: It was found that neighbourhoods belonging to the lowest quintile of income had a 42% more incidence than those belonging to the highest quintile: 942 cases per 100,000 inhabitants versus 545 per 100,000 inhabitants of the highest quintile. The Pearson correlation was statistically significative between the incidence of Covid-19 and the percentage of population over 75 (r=0.487), the percentage of immigration of the neighbourhood and the origin of the immigrants (r=-0.257), the AIFI (r=-0.462), the percentage of smokers (r=0.243) and the percentage of people with BMI over 25 (r=0.483). The GLM showed that the most correlated variables with the incidence are the percentage of people over 75 (Z-score=0.258), the percentage of people from Maghreb (Z-score=-0.206) and Latin America (Z-score=0.19) and the percentage of people with BMI over 25 (Z-score=0.334). The results of the GLM were significative. CONCLUSIONS: Social determinants are correlated with the modification of the incidence of Covid-19 in the neighbourhoods of Barcelona, with special relevance of the prevalence of BMI over 25 and the percentage of immigrants and its origin.


Subject(s)
Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , Social Determinants of Health , Adult , Betacoronavirus , Body Mass Index , Emigrants and Immigrants , Emigration and Immigration , Female , Health Services Accessibility , Health Status Disparities , Healthcare Disparities , Humans , Incidence , Male , Middle Aged , Pandemics , Residence Characteristics , Retrospective Studies , Smoking , Socioeconomic Factors , Spain/epidemiology
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