Monthly Analysis of Infant Mortality Rate in Portugal during the COVID-19 Pandemic: Insights from Continuous Monitoring.

INTRODUCTION: The COVID-19 pandemic significantly impacted global public health. Infant mortality rate (IMR), a vital statistic and key indicator of a population's overall health, is essential for developing effective health prevention programs. Existing evidence primarily indicates a decrease in IMR during the COVID-19 pandemic. We conducted a national-level analysis to calculate IMR and describe its course over the years (from 2016 until 2022), using a month-by-month analysis. METHODS: Data on the number of deaths under one year of age was collected from the Portuguese E-Death Certification System (SICO), and data on the number of monthly live births was obtained from Statistics Portugal. The IMR was calculated per month, considering the previous 12 months' cumulative number of deaths under one year of age and the number of live births. RESULTS: In Portugal, the IMR decreased before and during the COVID-19 pandemic. The lowest values were observed in September and October 2021 (2.15 and 2.14 per 1000 live births, respectively). The IMR remained below the threshold of three deaths per 1000 live births during the pandemic's critical period. CONCLUSION: Portugal has achieved remarkable progress in reducing its IMR over the last 60 years. The country recorded its lowest-ever IMR values during the COVID-19 pandemic. Further studies are needed to fully understand the observed trends.

Genomic and epidemiological insight of an outbreak of carbapenemase-producing Enterobacterales in a Portuguese hospital with the emergence of the new KPC-124.

BACKGROUND: Carbapenemase-producing Enterobacterales (CPE) is an increasing problem in healthcare settings. This study aimed to identify the source of a CPE outbreak that occurred in 2022, in a tertiary hospital in the North of Portugal, to identify exposed patients, and to assess the risk of becoming CPE-positive following hospital admission. METHODS: A multi-disciplinary investigation was conducted including descriptive, analytical, and molecular epidemiology, environmental screening, and assessment of infection control measures. Clinical and environmental isolates were analyzed using whole-genome sequencing and phylogenetic analysis. Additionally, a prospective observational cohort study was conducted to further investigate the risk factors associated with the emergence of new cases in cohorts of CPE-negative admitted patients. RESULTS: We observed the presence of multispecies KPC-, IMP-, and/or NDM-producing isolates. Genetically indistinguishable clinical and environmental isolates were found on the same room/ward. The ST45 KPC-3-producing Klebsiella pneumoniae clone was the responsible for the outbreak. During patients' treatment, we detected the emergence of resistance to ceftazidime-avibactam, associated with mutations in the blaKPC-3 gene (blaKPC-46, blaKPC-66 and blaKPC-124, the last variant never previously reported), suggesting a vertical evolutionary trajectory. Patients aged ≥ 75 years, hygiene/feeding-care dependent, and/or subjected to secretion aspiration were risk factors for CPE colonization after hospital admission. Additionally, cases with previous admission to the emergency department suggest that CPE dissemination may occur not only during hospitalization but also in the emergency department. CONCLUSION: Overall, the study highlights that selection pressure with antibiotics, like ceftazidime-avibactam, is a contributing factor to the emergence of new ß-lactamase variants and antibiotic resistance. It also shows that the hospital environment can be a significant source of CPE transmission, and that routine use of infection control measures and real-time molecular epidemiology investigations are essential to ensure the long-term termination of CPE outbreaks and prevent future resurgences.

Intersectoral collaboration in a One Health approach: Lessons learned from a country-level simulation exercise.

Intersectoral collaboration is an essential component of the One Health (OH) approach, which recognises the interconnectedness of the health of humans, animals, and the environment. The OH European Joint Programme (OHEJP) developed a national foodborne outbreak table-top simulation exercise (SimEx) to practice OH capacity and interoperability across the public health, animal health, and food safety sectors, improving OH preparedness for future disease outbreaks. The Portuguese OHEJP SimEx highlighted strengths and weaknesses regarding the roles and functions of available systems, the constraints of existing legislation, the importance of harmonisation and data sharing, and the creation of common main messages adapted to each target sector. However, there is still a long way to go to ensure cooperation among the Public Health, Animal Health, and Food Safety sectors, as a OH approach relies not only on the awareness of "field experts" but also on political and organisational willingness and commitment.

COVID-19 in Portugal: a retrospective review of paediatric cases, hospital and PICU admissions in the first pandemic year.

BACKGROUND: COVID-19 is considered by WHO a pandemic with public health emergency repercussions. Children often develop a mild disease with good prognosis and the recognition of children at risk is essential to successfully manage paediatric COVID-19. Quality epidemiological surveillance data are required to characterise and assess the pandemic. METHODS: Data on all reported paediatric COVID-19 cases, in Portugal, were retrospectively assessed from a fully anonymised dataset provided by the Directorate General for Health (DGS). Paediatric hospital admission results were obtained from the DGS vaccine recommendations and paediatric intensive care unit (PICU) admission results from the EPICENTRE.PT group. Reported cases and PICU admissions from March 2020 to February 2021 and hospital admissions between March and December 2020 were analysed. RESULTS: 92 051 COVID-19 cases were studied, 50.5% males, average age of 10.1 years, corresponding to 5.4% of children in Portugal. The most common symptoms were cough and fever, whereas gastrointestinal symptoms were infrequent. The most common comorbidity was asthma. A high rate of missing surveillance data was noticed, on presentation of disease and comorbidity variables, which warrants a cautious interpretation of results. Hospital admission was required in 0.93% of cases and PICU on 3.48 per 10 000 cases. PICU admission for Multisystem Inflammatory Syndrome in Children (MIS-C) was more frequent in children with no comorbidities and males, severe COVID-19 was rarer and occurred mainly in females and infants. Case fatality rate and mortality rates were low, 1.8 per 100 000 cases and 1.2 per 1 000 000 cases, respectively. CONCLUSIONS: The overall reported case incidence was 5.4 per 100 children and adolescents and <1% of cases required hospital admission. MIS-C was more frequent in patients with no comorbidities and males. Mortality and case fatality rates were low. Geographic adapted strategies, and information systems to facilitate surveillance are required to improve surveillance data quality.

Hepatitis C antibody prevalence and behavioral correlates in people who inject drugs attending harm reduction services in Lisbon, Portugal.

The hepatitis C virus (HCV) infection is an important public health problem, affecting millions of people worldwide. People who inject drugs (PWID) are at increased risk of HCV infection due to, among other factors, widespread unsafe injecting practices, such as sharing of infected equipment or unprotected sexual practices. In Portugal, there is a lack of data regarding the proportion of infected persons through injecting drug use. This study aimed to evaluate the anti-HCV prevalence and behavioral correlates of infection in PWID attending harm reduction services in the Metropolitan Area of Lisbon, Portugal. A cross-sectional study with a purposive sample of PWID was undertaken between March 2018 and March 2020. Participants were recruited through the harm-reduction services of a nongovernmental organization. A rapid diagnostic test for anti-HCV screening was performed. Data on drug consumption history and current practices, past HCV testing, care and treatment history, and knowledge regarding hepatitis C were also collected through a questionnaire applied by trained inquirers. A total of 176 PWID participated in this study. An overall prevalence of 70.5% of anti-HCV positive in this population was found. Those with an anti-HCV positive testing result tended to start consuming at a younger age and have a higher consumption of benzodiazepines in the last 30 days. Sharing needles and other injecting material is a frequent risk behavior among this group. Also, they are more likely to have attended an opioid agonist treatment and to have undertaken previous hepatitis C and HIV tests in the past. This study represents an important effort to better understand the HCV prevalence and behavioral correlates of infection among PWID in Portugal, as well as to better estimate those in need of HCV treatment.

Improving morbidity information in Portugal: Evidence from data linkage of COVID-19 cases surveillance and mortality systems.

BACKGROUND: COVID-19 rapidly spread around the world, putting health systems under unprecedented pressure and continuous adaptations. Well-established health information systems (HIS) are crucial in providing data to allow evidence-based policymaking and public health interventions in the pandemic response. This study aimed to compare morbidity information between two databases for COVID-19 management in Portugal and identify potential complementarities. METHODS: This is an observational study using records from both COVID-19 cases surveillance (National Epidemiological Surveillance System; SINAVE) and related deaths (National e-Death Certificates Information System; SICO) systems, which were matched on sex, age, municipality of residence and date of death. After the linkage, morbidity reported in SINAVE and identified in SICO, through the application of Charlson and Elixhauser comorbidity indexes algorithms, were compared to evaluate agreement level. RESULTS: Overall, 2285 matched cases were analyzed, including 53.9% males with a median age of 84 years. According to the method of data reporting assessment, the presence of any morbidity ranged between 26.3% and 62.5%. The reporting of ten morbidities could be compared between the information reported in SINAVE and SICO databases. The proportion of simultaneous reporting in both databases ranged between 5.7% for diabetes and 0.0% for human immunodeficiency virus infection or coagulopathy. Minimal or no agreement was found when assessing the similarity of the morbidity reporting in both databases, with neoplasms showing the highest level of agreement (0.352, 95% IC: 0.277-0.428; p < 0.001). CONCLUSION: Different information about reported morbidity could be found in two HIS used to monitor COVID-19 cases and related deaths, as data are independently collected. These results show that the interoperability of SICO and SINAVE databases would potentially improve available HIS and improve available information to decision-making and address COVID-19 pandemic management.

Multimorbidity Profile of COVID-19 Deaths in Portugal during 2020.

BACKGROUND: COVID-19 is caused by SARS-CoV-2 infection and has reached pandemic proportions. Since then, several clinical characteristics have been associated with poor outcomes. This study aimed to describe the morbidity profile of COVID-19 deaths in Portugal. METHODS: A study was performed including deaths certificated in Portugal with "COVID-19" (ICD-10: U07.1 or U07.2) coded as the underlying cause of death from the National e-Death Certificates Information System between 16 March and 31 December 2020. Comorbidities were derived from ICD-10 codes using the Charlson and Elixhauser indexes. The resident Portuguese population estimates for 2020 were used. RESULTS: The study included 6701 deaths (death rate: 65.1 deaths/100,000 inhabitants), predominantly males (72.1). The male-to-female mortality ratio was 1.1. The male-to-female mortality rate ratio was 1.2; however, within age groups, it varied 5.0-11.4-fold. COVID-19 deaths in Portugal during 2020 occurred mainly in individuals aged 80 years or older, predominantly in public healthcare institutions. Uncomplicated hypertension, uncomplicated diabetes mellitus, congestive heart failure, renal failure, cardiac arrhythmias, dementia, and cerebrovascular disease were observed among COVID-19 deceased patients, with prevalences higher than 10%. A high prevalence of zero morbidities was registered using both the Elixhauser and Charlson comorbidities lists (above 40.2%). Nevertheless, high multimorbidity was also identified at the time of COVID-19 death (about 36.5%). Higher multimorbidity levels were observed in men, increasing with age up to 80 years old. Zero-morbidity prevalence and high multimorbidity prevalences varied throughout the year 2020, seemingly more elevated in the mortality waves' peaks, suggesting variation according to the degree of disease incidence at a given period. CONCLUSIONS: This study provides detailed sociodemographic and clinical information on all certificated deaths from COVID-19 in Portugal during 2020, showing complex and extreme levels of morbidity (zero-morbidity vs. high multimorbidity) dynamics during the first year of the pandemic in Portugal.

Reply to Comment on Nogueira, P.J., et al. "The Role of Health Preconditions on COVID-19 Deaths in Portugal: Evidence from Surveillance Data of the First 20293 Infection Cases". J. Clin. Med. 2020, 9, 2368.

We thank Costa-Santos C [...].

The Role of Health Preconditions on COVID-19 Deaths in Portugal: Evidence from Surveillance Data of the First 20293 Infection Cases.

BACKGROUND: It is essential to study the effect of potential co-factors on the risk of death in patients infected by COVID-19. The identification of risk factors is important to allow more efficient public health and health services strategic interventions with a significant impact on deaths by COVID-19. This study aimed to identify factors associated with COVID-19 deaths in Portugal. METHODS: A national dataset with the first 20,293 patients infected with COVID-19 between 1 January and 21 April 2020 was analyzed. The primary outcome measure was mortality by COVID-19, measured (registered and confirmed) by Medical Doctors serving as health delegates on the daily death registry. A logistic regression model using a generalized linear model was used for estimating Odds Ratio (OR) with 95% confidence intervals (95% CI) for each potential risk indicator. RESULTS: A total of 502 infected patients died of COVID-19. The risk factors for increased odds of death by COVID-19 were: sex (male: OR = 1.47, ref = female), age ((56-60) years, OR = 6.01; (61-65) years, OR = 10.5; (66-70) years, OR = 20.4; (71-75) years, OR = 34; (76-80) years, OR = 50.9; (81-85) years, OR = 70.7; (86-90) years, OR = 83.2; (91-95) years, OR = 91.8; (96-104) years, OR = 140.2, ref = (0-55)), Cardiac disease (OR = 2.86), Kidney disorder (OR = 2.95), and Neuromuscular disorder (OR = 1.58), while condition (None (absence of precondition); OR = 0.49) was associated with a reduced chance of dying after adjusting for other variables of interest. CONCLUSIONS: Besides age and sex, preconditions justify the risk difference in mortality by COVID-19.

Excess Mortality Estimation During the COVID-19 Pandemic: Preliminary Data from Portugal.

INTRODUCTION: Portugal is experiencing the effects of the COVID-19 pandemic since March 2020. All-causes mortality in Portugal increased during March and April 2020 compared to previous years, but this increase is not explained by COVID-19 reported deaths. The aim of this study was to analyze and consider other criteria for estimating excessive all-cause mortality during the early COVID-19 pandemic period. MATERIAL AND METHODS: Public data was used to estimate excess mortality by age and region between March 1 and April 22, proposing baselines adjusted for the lockdown period. RESULTS: An excess mortality of 2400 to 4000 deaths was observed. Excess mortality was associated with older age groups (over age 65) [corrected]. DISCUSSION: The data suggests a ternary explanation for early excess mortality: COVID-19, non-identified COVID-19 and decrease in access to healthcare. The estimates have implications in terms of communication of non-pharmaceutical actions, for research, and to healthcare professionals. CONCLUSION: Despite the inherent uncertainty, the excess mortality occurred between March 1 and April 22 could be 3.5- to 5-fold higher than what can be explained by the official COVID-19 deaths [corrected].

Introdução: Desde março 2020, Portugal tem sofrido os efeitos da pandemia COVID-19. A mortalidade por todas as causas aumentou em março e abril de 2020 comparativamente a anos anteriores, mas este aumento não é explicado pelas mortes reportadas de COVID-19. O objetivo deste estudo foi analisar e considerar outros critérios para estimar o excesso de mortalidade durante a pandemia COVID-19. Material e Métodos: Utilizaram-se bases de dados públicas para estimar o excesso de mortalidade por idade e região entre 1 de março e 22 de abril, propondo níveis basais ajustados ao período de estado de emergência em vigor. Resultados: Apesar da incerteza inerente, é seguro assumir um excesso de mortalidade observada de 2400 a 4000 mortes. O excesso de mortalidade encontra-se associado aos grupos etários mais idosos (idade superior a 65 anos). Discussão: Os dados sugerem uma explicação tripartida para o excesso de mortalidade: COVID-19, COVID-19 não identificado e diminuição do acesso a cuidados de saúde. As estimativas efetuadas possuem implicações ao nível da comunicação de acções não farmacológicas, da investigação científica e dos profissionais de saúde. Conclusão: Da análise dos resultados é possível concluir que o excesso de mortalidade ocorrido entre 1 de março e 22 de abril foi 3 a 5 vezes superior ao explicado pelas mortes por COVID-19 reportadas oficialmente.

Effects of economic recession on elderly patients' perceptions of access to health care and medicines in Portugal.

Background In view of the current financial and demographic situation in Portugal, accessibility to health care may be affected, including the ability to adhere to medication. Objective To evaluate the perceived effects of the crisis on elderly patient's access to medicines and medical care, and its implications on medicine-taking behaviour. Setting Community pharmacy. Method A cross-sectional study was undertaken during April 2013, where elderly patients answered a self-administered questionnaire based on their health-related experiences in the current and previous year. Binary logistic regression was used to ascertain the effects of potential predictors on the likelihood of adherence. Main outcome measures self-reported adherence. Results A total of 1231 questionnaires were collected. 27.3% of patients had stopped using treatments or health services in the previous year for financial motives; mostly private medical appointments, followed by dentist appointments. Almost 30% of patients stopped purchasing prescribed medicines. Over 20% of patients reduced their use of public services. Out-of-pocket expenses with medicines were considered higher in the current year by 40.1% of patients. The most common strategy developed to cope with increasing costs of medicines was generic substitution, but around 15% of patients also stopped taking their medication or started saving by increasing the interdose interval. Conclusion Reports of decreasing costs with medicines was associated with a decreased likelihood of adherence (OR 0.42; 95% CI 0.27-0.65). Lower perceived health status and having 3 or more co-morbidities were associated with lower odds of adhering, whilst less frequent medical appointments was associated with a higher likelihood of exhibiting adherence.

Molecular epidemiology of Mycobacterium tuberculosis in Lisbon.

We conducted a molecular epidemiology study of Mycobacterium tuberculosis strains isolated from patients in Lisbon hospitals. We used restriction fragment length polymorphism (RFLP) to detect Lisbon family strains and to determine the genetic diversity of Mycobacterium tuberculosis strains isolated in Lisbon, through identification of the most important risk factors of tuberculosis transmission analysis, with the insertion sequence IS6110 as a probe to fingerprint isolates of Mycobacterium tuberculosis. 64.8% of the 290 Mycobacterium tuberculosis isolates were grouped in clusters. This figure was 60.7% if we excluded strains with five or fewer IS6110 copies. Multidrug-resistance was observed in 4.1% of the strains and they were all in clusters. Forty-five (18.2%) strains were included in the Lisbon family. Considering the relatively high percentage of strains in cluster detected in this study, we believe that active transmission is still taking place in Lisbon. Moreover, clusters of Lisbon strains represent the predominant strains circulating in Lisbon and are still related to drug resistance although presenting a lower percentage than that observed in previous studies.

[Laboratory surveillance of drug resistance tuberculosis in Portugal in 2000-2001]. / Vigilância laboratorial da resistência aos antibacilares em Portugal em 2000-2001.

BACKGROUND: A network for the Surveillance of Antituberculosis Drug Resistance (VigLab-Tuberculose), including all the mycobacterial laboratories where drug susceptibility test on isolates of Mycobacterium tuberculosis complex are carried out, was established in Portugal in April 2000. VigLab-Tuberculose aims to maintain a laboratory-based surveillance system for antibiotic susceptibilities of Mycobacterium tuberculosis complex isolates in order to monitor trends in drug resistance in Portugal. OBJECTIVE: To describe the first line antituberculosis drug resistance patterns of tuberculosis cases diagnosed and reported to VigLab-Tuberculose in 2000-2001. METHODS: Collaborating laboratories collect and report data on individuals from whom a drug susceptibility test on Mycobacterium tuberculosis complex isolates has been performed in 2000-2001. Data collected included demographic, geographic, clinical and first line antibiotics susceptibility information. Data were analysed using Epi-Info version 6.04c software. RESULTS: There were 4170 reports of drug susceptibility test results on tuberculosis patients diagnosed from 1st April 2000 to 31st December 2001. Drug susceptibility results for all five first line antituberculosis drugs shows that 23% (541/2358) were resistant at least to one of them. The proportion of mono-resistance to streptomycin was 7,6% (179/2358), to isoniazid 2,6% (62/2358), to rifampicin 0,6% (15/2358) and to pyrazinamide 1,3% (30/2358). From the 4164 patients tested both to isoniazid and rifampicina, 244 (5,9%) were multidrug resistant. From patients with no history of previous tuberculosis treatment, 1,8% (28/1557) were mono-resistant to isoniazid, 0,4% (7/1557) to rifampicina, 4,2% (66/1557) to streptomycin and 1,7% (27/1557) to pyrazinamide. The proportion of primary multidrug resistance was 2,8% (43/1557) and acquired resistance was 13,3% (41/309). CONCLUSION: The laboratory participation rate was 80%, which is very encouraging for the first two years of VigLab-Tuberculose activities. The proportion of primary multidrug resistance was higher than the reported resistance from central and west Europe (less 1%), which reinforce the need and importance of maintaining and strengthening the laboratory-based surveillance in order to minimise the emergence of drug resistance.