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Centro Nacional de Epidemiología19 Enero 2017
Ciudades y Salud Cardiovascular: Proyecto ERC Heart Healthy Hoods
@HHHproject Manuel Franco MD, PhD
Profesor Titular Universidad de Alcalá
Adjunct Associate ProfessorDepartment of Epidemiology
Johns Hopkins Bloomberg School of Public Health
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http://hhhproject.eu
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http://hhhproject.eu
Physical activity environment in Madrid, HHH study
International Journal of Epidemiology 2015, Franco M et al
Miguel, 45 years old, lives in Villaverde, Madrid. Low-income area.
Miguel goes out for a walk every afternoon to the park. “I used to run all the distance of the bike lane but I started having knee problems and now I prefer walking. When I am in a good mood I can walk all the way to the next large neighbourhood.”
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http://hhhproject.eu
Food environment in Madrid, HHH study
International Journal of Epidemiology 2015, Franco M et al.
María, 45 ys, resident of Villaverde. Low-income area. María and her friends meet twice per week to have a dinner snack at the Dehesa Boyal park, a pinewood and main park in San Cristobal. María lives in Spain for the last 4 years, unemployed for the last 8 months, and she often thinks about coming back to the Dominican Republic where her family lives.
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http://hhhproject.eu
Opportunities for NCDs prevention within
Urban Health Research1. By 2050: 66% of the world population will live in cities2. Challenge of aging and chronic diseases already in our cities 3. Social determinants as working conditions, unemployment
and poverty are clearly patent in our cities4. Segregation patterns and health inequalities are social
phenomena measurable in our cities
5. Cities, municipalities, districts, offer great (structural)1 opportunities to improve population health
6. New sources and types of health and urban data, allong with novel methodologies and interdisciplinary teams
7. Urban health research is directly linked to action(1) Franco, Bilal and Diez-Roux, J Epidemiol Comm Health 2015
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Social and Physical Urban Environment and CV Health:
The Much Needed Population Approach
Manuel Franco MD, PhD
Starting Grant 2013 Start Date April 1st 2014
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Presenter’s Name
Date
PhysicalEnvironment
Social Environment
SOCIALEPIDEMIOLOG
YStudies social determinants of disease
Methodologies from Social Sciences and Public Health
Focus on population preventive approach
Addresses growing social inequalities in health
First cause of death in Europe (47% of all deaths in 2010)
Increasing prevalence (50 mill. patients in 2009 in Europe)
Rising social and economic costs (196 billion € in 2009)
Traditional medical preventive approaches are individual
CardiovascularHealth
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Presenter’s Name
Date
PhysicalEnvironment
Social Environment
CardiovascularHealth
HEARTHEALTHYHOODS
Obesity
Physical Activity
DietAlcohol
Physical ActivityEnvironment
Food Environment
CVD
Smoking
Tobacco Environment
Social and PhysicalEnvironment
Individual Cardiovascular Health
AlcoholEnvironmentN
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Soci
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Heart Healthy Hoods Study Main Goal
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http://hhhproject.eu
1. To include a qualitative approach to understand the context and meanings of the urban environment in relation to cardiovascular health
2. To develop measurements to characterize the social and physical urban environments in a systematic and accurate fashion
3. To understand the already known relation between the urban environment and cardiovascular health in the United States with this relation in Europe
Heart Healthy Hoods Secondary Objectives
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http://hhhproject.eu
To provide scientific evidence to researchers, the
general population and policy makers to intervene at
the population level to prevent the first cause of
death in Europe.
HHH overarching objectivePolicy and research implications
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http://hhhproject.eu
Photography Knowledge
DisseminationCitizen Science
Epidemiology
Health SociologyUniversity of Salamanca
Johns Hopkins School of Public Health
GeographyUniversity of AlcaláCRESH EdinburghLSHTM
Primary Care System Primary Care Research Unit, Madrid
Interdisciplinary team PI: Social Epidemiology
University of AlcaláJohns Hopkins School of Public Health
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http://hhhproject.eu
INTERDISCIPLINARY TEAM
https://hhhproject.eu/people/
Madrid Team
International Collaborations
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http://hhhproject.eu
HHH Kick off meetingSeptember 2014
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http://hhhproject.eu
21 Districts128 Neighborhoods2.412 Census Sections (≅1.500 ps) 3,2 Mill. Residents
HHH will analyze the Integrated Primary Care Health System Electronic Health Records Database of 1,4 mill. residents 40-75 ys.
MADRID
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http://hhhproject.eu
HHH Study Design
Baseline VisitCohort Study
1st Database Mining
Population-based EHR
study4 yr follow up
2,576 participants Final Visit
Final Database Mining
1,4 million people
EnvironmentTobacco Alcohol
FoodPhysical Activity
1st Assessment 2nd AssessmentNeighborhoods
Multilevel AssociationAnalysis
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http://hhhproject.eu
To describe CV profile of adult population (40-75 years)
from the city of Madrid. Likewise, to investigate the
association between social and physical features of
the urban environment with citizens’ CV health.
WHHHole-Population Study
Using…• Electronic Health Records for CV Health (Almost 1,5
million people). • Several secondary databases for urban environment.
Overall Objective
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http://hhhproject.eu
Whole-Population Study Secondary Objectives
1. To describe CVD annual incidence
2. To describe behavioral and biological risk factors
prevalence and incidence
3. To study the association between sociodemographic
profile and urban environment with CVD incidence
4. To study the Whole-Population results as compared
to HHH Cohort results
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http://hhhproject.eu
Primary Healthcare Centers of MadridCohort HHH centers
1 C.S. ADELFAS2 C.S. ALPES3 C.S. ANGELA URIARTE4 C.S. ARTILLEROS5 C.S. BARAJAS6 C.S. CARAMUEL7 C.S. CERRO ALMODOVAR8 C.S. CIUDAD JARDIN9 C.S. DAROCA
10 C.S. DR. CASTROVIEJO11 C.S. ELOY GONZALO12 C.S. ENTREVIAS13 C.S. ESPRONCEDA14 C.S. FEDERICA MONTSENY15 C.S. FUENCARRAL
16 C.S. GARCIA NOBLEJAS17 C.S. GENERAL RICARDOS18 C.S. GUAYABA19 C.S. IBIZA20 C.S. LAGASCA21 C.S. LAS CORTES22 C.S. LAVAPIES23 C.S. LOS YEBENES24 C.S. MAR BALTICO25 C.S. MONOVAR26 C.S. PAVONES27 C.S. SAN ANDRES28 C.S. SAN FERMIN29 C.S. TORITO30 C.S. VALDEBERNARDO31 C.S. VILLAAMIL
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http://hhhproject.eu
The CoHHHort Study
Main Objective:To study the association between environment characteristics and diet, smoking, physical activity, alcohol consumption, and cardiovascular risk
Target Population:- Men and women between 40 and 75 years old- Free of cardiovascular disease- Residents of Madrid city- Origin: Ecuador, Colombia, Perú y Bolivia
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http://hhhproject.eu
21 Madrid districts
31 Primary Healthcare centers
Sample sizeN=2576
370 Physicians and nurses trained
The CoHHHort Study
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http://hhhproject.eu
Clinical visit
Telephone survey
Biological cardiovascular risk factors
Behavioral cardiovascular risk factors
The CoHHHort Study
Variables:
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http://hhhproject.eu
2017 Follow-up 2018
Follow-up 2019
Follow-up 2020
Clinical visit+
Telephone survey
Electronic health
records variables
Clinical visit+
Telephone survey
Electronic health
records variables
Cohort Study calendar:
The CoHHHort Study
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http://hhhproject.eu
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http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Median Area of Madrid (Usama Billal)
b) Results by domainsa) Food
b) Physical Activity
c) Tobacco
d) Alcohol
c) Results by working groupsa) Urban Geography
b) Qualitative Research
HHH Analyses and Results
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http://hhhproject.eu
Mixed Methods Approach
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http://hhhproject.eu
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http://hhhproject.eu
Methods (quantitative)
• Cardiovascular Disease:– Whole population (>99%) EHR through universal health system.– Validated (1) data on physician-diagnosed: diabetes, hypertension,
dyslipidemia, smoking and obesity.
• Urban environment– Food: location and type of food stores and food services, directly
measured healthy food availability (brief NEMS-S)– Physical activity: SPACES audit tool for walkability and bikeability,
SOPARC audit tool for open spaces.– Alcohol and tobacco: location and type of retailers
References: (1) de Burgos Lunar et al, BMC Med Res Methodol, 2013.
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http://hhhproject.eu
Methods (qualitative)
• 11 semi-structured interviews with key informants: 4 long-term residents, 2 recent immigrants, 1 teacher, 1 community activist, 1 health care provider, 1 public health officer, 1 local food store owner
• Questions on health and the environment, focusing on sociodemographics, food, alcohol, tobacco and physical activity.
• Analysis by triangulation incorporating an interpretative phenomenological analysis.
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http://hhhproject.eu
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http://hhhproject.eu
Exploratory Study Sociodemographic ProfilePrimary Health Care Records
• Total Pilot Area Population: 15,751
• Population in the Primary Care Health System Geocoded to
census section level: 14,857 (95%)–Possibility of analyzing data for 1.4 million people
• Population 45-106 ys. old: 7,252
• Diabetes Prevalence: 12%
• Diabetes Control (HbA1c<7): 63%
• Hypertension Prevalence: 34%
• Dyslipidemia, all types: 32%
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http://hhhproject.eu
Métodos Medidas de Exposición Barrios
42 neighborhoods in Madrid (2 neighborhoods per district selected
according different SE charactersitics)
In each neighborhood we select the “median” census track in terms of
educational level, immigration, density of business and age.
Representative area of the municipality of Madrid in terms of SE characteristics
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http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domains
a) Food (Julia Diez) b) Physical Activity
c) Tobacco
d) Alcohol
c) Results by working groups
a) Urban Geography
b) Qualitative Research
HHH Analyses and Results
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http://hhhproject.eu
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http://hhhproject.eu
Cross-city differences
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http://hhhproject.eu
Walking access to healthy foodMADRID BALTIMORE
Preventive Medicine 2016, Diez J et al.
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http://hhhproject.eu
Food environment measures• Methods
1) Ground-truthing (in-store audits)
• Observers assessed all food stores present in all 42
census sections (June-July 2016), using a web-based
app, to measure healthy food availability and price.
2) Secondary database
• Public database “Censo de Locales”, updated monthly
and freely accessible from the city council.
• We assessed level of agreement by store type and by
census section-SES
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http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domainsa) Food
b) Physical Activity (Pedro Gullón) c) Tobacco
d) Alcohol
c) Results by working groups
a) Urban Geography
b) Qualitative Research
HHH Analyses and Results
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http://hhhproject.eu
Urban Environment and active transportation in Madrid
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http://hhhproject.eu
Madrid Systematic Pedestrian and Cycling Environment Scan (M-SPACES)
- Function- Safety- Aesthetics- Destinations
M-SPACES AUDIT TOOL
Pedro Gullón et al. September 2015 Journal of Urban Health,
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http://hhhproject.eu
Physical Activity Results
Pedro Gullón et al. September 2015 Journal of Urban Health,
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Pedro Gullón, Usama Bilal, Alba Cebrecos, Hannah M. Badland, Francisco Escobar, Iñaki Galán, Manuel Franco
Under Review: International Journal of Health Geographics
Socioeconomic Determinants of Small-Area Walkability in a European city like
Madrid: The Heart Healthy Hoods Project
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http://hhhproject.eu
Figure 1. Spatial distribution of Walkability Index (a) and Socio-Economic Status Index (b) by deciles in the census section (N=2415) of the city of Madrid
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http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domainsa) Food
b) Physical Activity
c) Tobacco (Xisca Sureda) d) Alcohol
c) Results by working groups
a) Urban Geography
b) Qualitative Research
HHH Analyses and Results
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Tobacco retail environment, outdoor smoke-free policies
and smoking
HHH Ancillary Study PI: Xisca Sureda
Co-investigators: M. Franco, U. Bilal, FJ Escobar, A Navas, E. Fernández
Alcalá University, ICO Barcelona, Johns Hopkins Bloomberg School of Public Health, Columbia University
Funding: European Research Council Starting Grant 2013 HeartHealthyHoods Agreement n. 336893 and Instituto de Salud Carlos III (PI15/02146)
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Tobacco in HHH
http://hhhproject.eu
1. To describe tobacco environment in neighborhoods in Madrid city in terms of:
1.1 Tobacco availability (point of sales of tobacco, volume of sales)
1.2 Signs of tobacco consumption outdoors (hospitality venues and other public spaces)
1.3 Second-hand smoke exposure interraces of bars and restaurants
2. To determine possible differences between tobacco urban environment and smoking behaviour and self-reported SHS exposure
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DENSITY OF TOBACCO POINT OF SALES LOW EDUCATIONAL LEVEL
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http://hhhproject.eu
Outdoor tobacco consumption signs
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http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domainsa) Food
b) Physical Activity
c) Tobacco
• Alcohol (Madrid, Barcelona, Edinburgh, Baltimore)a) Results by working groups
a) Urban Geography
b) Participatory Action Research PHOTOVOICE
HHH Analyses and Results
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Alcohol urban environment, and the implementation of
regulatory policies
HHH Ancillary Study PI: Xisca Sureda
Co-investigators: M. Franco, J Pearce, M. Lazo-Elizondo, FJ Escobar, MV. Sandín
Alcalá University, Johns Hopkins Bloomberg School of Public Health, University of Edinburgh
Funding: European Research Council Starting Grant 2013 HeartHealthyHoods Agreement n. 336893 and Plan Nacional sobre Drogas (2016I047)
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Alcohol in HHH
Sureda X, Villalbí JR, Espelt A, Franco M. Living under the influence: Normalization of alcohol consumption in our cities. Gac Sanit. 2017; vol 31(1): 66-68
1. To describe alcohol environment in in terms of availability, promotion and signs of consumption.
1.1 To determine possible differences between alcohol urban environment and alcohol drinking behaviour.
2. To conduct a participatory-action research strategy (Photovoice) to better understand the attitudes and practices in relation to alcohol consumption from a cultural and social perspective.
3. To compare the regulation of the alcohol urban environment and its implementation in Madrid and Barcelona and how these policies determine possible differences
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OHCITIES instrument
Sureda X, Espelt A, Villalbí JR, Cebrecos A, Baranda L, Pearce J, Franco M. Development and validation of the OHCITIES instrument: Assessing alcohol urban environments in the Heart Healthy Hoods project. (submitted)
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OHCITIES Validation Results
http://hhhproject.eu
53,7% with promotion associated to the outlet
88,2% with promotion associated to the outlet
Sureda X, Espelt A, Villalbí JR, Pearce J, Franco M. Alcohol in the city: wherever and whenever. (submitted)
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a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domainsa) Food
b) Physical Activity
c) Tobacco
d) Alcohol (Xisca Sureda)
c) Results by working groups
a) Urban Geography (Alba Cebrecos)b) Qualitative Research
HHH Analyses and Results
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The aim was to design and implement a multicomponent method based on Geographic Information Systems to characterize and evaluate environmental correlates of obesity: the food and the physical activity urban environments.
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f̂ ( x )= 1h𝑛 ∑i=1
n
K ( x− X ih )
Kernel Density Estimation (KDE)
WALKABILITY
HFAI
HFAI & WALKABILITY
STUDY AREA
METHODOLOGY
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RESULTS
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a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domainsa) Food
b) Physical Activity
c) Tobacco
d) Alcohol
c) Results by working groupsa) Urban Geography
b) Qualitative Research (Paloma Conde)
HHH Analyses and Results
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Neighborhoods under change and residents´ health perceptions: The Heart Healthy Hoods qualitative study.
Objectives:•To describe the social and neighborhood changes occurring in a middle low socioeconomic area of Madrid according to their residents.
•To explore how these neighborhood changes are connected to residents’ health perceptions.
Methods: Exploratory qualitative study within 12 months (from January 2014 to January 2015) using 16 semi-structured interviews. Residents + professionals.
Interview Topic guide:- Neighborhood description- Uses of the neighborhood- Health related to neighborhood
Conde P, Gutiérrez M, Sandín M, Díez J, Rivera J, Franco M. Neighborhoods under change and residents´ health perceptions: The Heart Healthy Hoods qualitative study (submitted)
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Breakdown of traditional forms vs IndividualismRapid rhythms of life (-) Lack of timeChange in gender/age role
Generation and cultural
fracture
NEIGHBORHOOD CHANGES
Economic crisisImpoverishment and lack of resourcesHigh working hours
SOCIAL CHANGES
New Demographic composition
New socio-cultural values
Economic aspects
Qualitative results RESIDENTS’ HEALTH PERCEPTIONSLoss of trust relationships
(-) Loneliness and lack of social support
New diet practices(-) Not very healthy diets
New uses of public spaces(-) Loss of public space use
Associative networks support(+) Strengthen self-esteem(+) Decreases anxiety(+) Increases social cohesion
Participation of elderly in health promotion and education programs
(+) Promotes Active ageing
Unemployment and job insecurity(-) Unhealthy diets(-) Stress, Anxiety
(+) Intergenerational solidarity
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HHH Ancillary Studies
1. Photovoice Villaverde, 2015
2. Usama´s Retrospective HHH, 2015-2016
3. Smoking in the City, 2016-2019
4. Qualitative HHH substudy, 2017-2020
5. Alcohol in the City, 2017-2020
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HHH Current Scientific Achievements
• 8 international papers and 4 book chapters
• Bilingual photobook and public exhibition
• 5 funded ancillary studies
• 3 Predoctoral and one Erasmus master fellowships
• Intramural: 3 research awards Universidad de Alcalá
• 4 travel grants for US (Joel Gittelsohn and Luisa Borrell) and UK researchers (Daniel Lewis and Jamie Pearce)
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• Participants
• Whole HHH Madrid team and collaborations
• Different funding agencies: • European Research Council• Ayuntamiento y Comunidad de Madrid • Fondo de Investigación Sanitaria• Plan Nacional de Investigación• Plan Nacional Sobre Drogas• Fundación Mapfre• Center for a Livable Future, Johns Hopkins
Acknowledgements
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HHH TeamThank you very much !
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Centro Nacional de Epidemiología19 Enero 2017
¡ Gracias ! Todos los investigadores HHH
y Manuel Franco
@HHHproject