Association between area-level walkability and glycated haemoglobin: a Portuguese population-based study.

Diabetes poses a substantial disease burden, prompting preventive interventions. Physical inactivity, a major risk factor for type 2 diabetes, can potentially be mitigated by enhancing area-level walkability. Despite this, limited population-based studies have investigated the link between walkability and objective diabetes measures. Our study aims to estimate the association between area-level walkability and individual glycated haemoglobin levels in the Portuguese adult population without the diagnosis of diabetes. Data from the 2011 census and an updated street map were obtained to construct a walkability index based on residential density, land-use mix, and street connectivity. Individual health data were sourced from The National Health Examination Survey (INSEF) 2015, a representative survey of the Portuguese adult population. Gamma regression was employed for estimation of the main associations, revealing that residing in moderately walkable areas significantly reduced average glycated haemoglobin levels (Exp(ß) = 0.906; 95% CI: 0.821, 0.999) compared to the least walkable areas. The association was less pronounced and not statistically significant for the third tertile of walkability (Exp(ß) = 0.919; 95% CI: 0.822, 1.028). Our findings highlight a nonlinear protective association between walkability and glycated haemoglobin, emphasizing the potential policy implications for urban planning, diabetes prevention, and health promotion.

Investigating the association between ambient particulate matter (PM10) exposure and blood pressure values: Results from the link between the Portuguese Health Examination Survey and air quality data.

INTRODUCTION AND OBJECTIVES: High blood pressure (BP) remains a major modifiable cardiovascular (CV) risk factor. Several epidemiologic studies have been performed to assess the association between air pollution exposure and this CV risk factor but results remain inconsistent. This study aims to estimate the effect of short-term PM10 exposure (average previous three-day concentration) on diastolic (DBP) and systolic (SBP) blood pressure values of the resident mainland Portuguese population. METHODS: Our study was based on available DBP and SBP data from 2272 participants from the first Portuguese Health Examination Survey (INSEF, 2015) living within a 30 km radius of at least one air quality monitoring station, with available measurements of particulate matter with an aerodynamic equivalent diameter ≤10 µm (PM10). We used data from the air quality monitoring network of the Portuguese Environment Agency to obtain the individual allocated PM10 concentrations. Generalized linear models were used to assess the effect of PM10 exposure on DBP and SBP values. RESULTS: No statistically significant association was found between PM10 exposure and both DBP and SBP values (0.42% DBP change per 10 µg/m3 of PM10 increment (95% confidence interval (CI): -0.85; 1.70) and 0.47% SBP change per 10 µg/m3 of PM10 increment (95% CI: -0.86; 1.79)). Results remain unchanged after restricting the analysis to hypertensive or obese participants or changing the PM10 assessment methodology. CONCLUSIONS: In view of the PM10 levels observed in 2015, our results suggests that exposure to PM10 concentrations have a small or no effect on the blood pressure values. Other air pollutants and mixtures of pollutants that were not included in our study should considered in future studies.

Evaluation of the European Health Information Training Programme (EHITP): results from InfAct Joint Action.

BACKGROUND: The InfAct (Information for Action) is a Joint Action of the European Commission's 3rd Health Programme with the main goal to build an infrastructure of a health information system for a stronger European Union and to strengthen its core elements. The InfAct Joint Action was developed along 36 months and structured in 10 work packages. Portugal co-led the Work Package 6 (WP6) of this project, which included the development of the proposal of a flagship capacity building programme - the European Health Information Training Programme - and its evaluation. The evaluation objectives included: to evaluate the adequacy of the training programme to the health information needs in the European Member States; to identify possible changes regarding the participants selection process, the training activities and the pedagogical project; and to contribute to the understanding of the potential of the programme to add to available offers in learning on the topics of Public Health information, on the capacity building and behavioural changes in Public Health activities which can be attributed to the course, and of the potential of the programme to contribute to the alignment of health information criteria and procedures between the European Member States. METHODS: The evaluation process was developed using an observational descriptive study design using a mixed methodological approach with both document analysis and primary data collected by questionnaires and interviews analysis. Mixed quantitative and qualitative data collection methods and analysis were used. RESULTS: The proposal of the European Health Information Training Programme seemed adequate to the formative needs and capacities in line with the work performed by the InfAct project. In what concerns about its main thematic areas, it was also aligned with the areas identified in the previous formative needs and capacities mapping. The participants selection process proposed seemed, in general, adequate. The potential of the European Health Information Training Programme proposal to learning, capacity building and behavioral changes at work attributable to the course was considered positive, as well as the potential to the alignment of health information criteria and procedures between European Union Member States. DISCUSSION: In general, we found high consistency between the results obtained from data collected by the techniques used. However, different suggestions for improvement were outlined by the evaluation study population. CONCLUSIONS: The proposed European Health Information Training Programme was a dynamic, flexible, sustainable formative programme in health information and focused on reducing inequalities.

SARS-CoV-2 seroprevalence in Portugal following the third epidemic wave: results of the second National Serological Survey (ISN2COVID-19).

BACKGROUND: Integrated approaches to surveillance of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection are important for public health actions. The 2nd National Serological Survey (ISN2COVID-19) aimed to characterize the extent of SARS-CoV-2 infection and vaccine-induced response in the Portuguese population following the third epidemic wave and the launch of the vaccination campaign. METHODS: A cross-sectional study was performed using data on 8463 Portuguese 1-79 years of age, collected in February and March, 2021. SARS-CoV-2 IgM and IgG (anti-nucleoprotein and anti-spike) antibodies were determined in serum samples using Abbott Architect chemiluminescent microparticle assays. Post-infection and vaccine-induced seroprevalence with 95% confidence intervals (95%CI) were estimated in the overall sample and stratified by population characteristics. RESULTS: The estimated seroprevalence was 15.5% (95%CI:14.6-16.5%), of which 13.5% (95%CI: 12.6-14.4%) was attributable to natural infection and 2.0% (95%CI:1.7-2.4%) to vaccination. The lowest seroprevelence was observed in persons aged 70-79 years (8.9% 95%CI:6.8-11.6), while seroprevalence in children (14.3%; 95%CI:11.5-17.6%) and adolescents (12.9%; 95%CI:10.5-15.7%) was similar to that of persons aged between 20 and 69 years. Of seropositive individuals, 22.6% (95%CI:19.7-25.9%) did not report any symptoms in 6 months prior to interview. Of persons with completed vaccination (2-doses), 98.6% (95%CI: 93.0-99.7%) had specific IgG (anti-S) antibodies. CONCLUSIONS: After the third epidemic wave, the post-infection SARS-CoV-2 seroprevalence was 1.7 times higher than the cumulative incidence based on PCR-testing, but was higher (2.7 times) in children may be due to the high proportion of asymptomatic and mild infections.

PM10 exposure interacts with abdominal obesity to increase blood triglycerides: a cross-sectional linkage study.

BACKGROUND: Blood lipids and glucose levels dysregulation represent potential mechanisms intermediating the adverse cardiovascular effects of ambient particulate matter (PM) exposure. This study aims to estimate the effect of long-term PM10 exposure on blood lipids and glucose levels and to assess the potential mediation and/or modification action of abdominal obesity (AO) (waist-to-height ratio). METHODS: Our study was based on 2,390 participants of the first Portuguese Health Examination Survey (INSEF, 2015) with available data on blood lipids and glucose parameters and living within a 30-km radius of an air quality monitoring station with available PM10 measurements. PM10 concentrations were acquired from the air quality monitoring network of the Portuguese Environment Agency. Generalized linear models were used to assess the effect of 1-year PM10 exposure on blood lipids and glucose levels. An interaction term was introduced in the models to test the modification action of AO. RESULTS: We found an association between PM10 and non-fasting blood triglycerides (TG) after adjustment for age, sex, education, occupation, lifestyles-related variables and temperature but only in participants with AO. Per each 1 µg/m3 PM10 increment, there was a 1.84% (95% confidence interval: 0.02-3.69) increase in TG. For the remaining blood lipid and glucose parameters, no associations were found. CONCLUSIONS: Our study demonstrates that even at low levels of exposure, long-term PM10 exposure interacts with AO to increase blood TG. Our findings suggest that reducing both AO prevalence and PM10 below current standards would result in additional health benefits for the population.

Association between area- and individual-level socio-economic factors with glycated haemoglobin-Evidence from a Portuguese population-based study.

AIMS: This study aims to estimate the associations between area-level deprivation and individual-level socio-economic factors, as well as their interaction, with glycated haemoglobin (HbA1c ) levels. METHODS: We conducted a gamma multilevel regression analysis using individual-level data from the Portuguese National Health Examination Survey and a deprivation index built through factor analysis, at municipality level, with census variables. RESULTS: Living in a municipality with high material deprivation and having a low level of education were independently associated with an increase of 2.3% (95% confidence interval [CI] 0.6, 4.0) and of 1.6% (95% CI 0.6, 2.7) in the mean levels of HbA1c , respectively. The interaction between area material deprivation and individual-level education was not associated with the levels of HbA1c (0.5%, 95% CI -1.3, 2.3). CONCLUSIONS: Our findings support the collective resources model that argues that people in less deprived areas have better health because there are more collective resources. The results suggest that to reduce socio-economic inequalities associated with the levels of HbA1c and, consequently, with diabetes, will require attention to the area material deprivation and individual-level education. Upstream social determinants of health are thus highlighted.

Seasonal Dynamics and Spatial Distribution of Aedes albopictus (Diptera: Culicidae) in a Temperate Region in Europe, Southern Portugal.

Aedes albopictus is an invasive mosquito that has colonized several European countries as well as Portugal, where it was detected for the first time in 2017. To increase the knowledge of Ae. albopictus population dynamics, a survey was carried out in the municipality of Loulé, Algarve, a Southern temperate region of Portugal, throughout 2019, with Biogents Sentinel traps (BGS traps) and ovitraps. More than 19,000 eggs and 400 adults were identified from May 9 (week 19) and December 16 (week 50). A positive correlation between the number of females captured in the BGS traps and the number of eggs collected in ovitraps was found. The start of activity of A. albopictus in May corresponded to an average minimum temperature above 13.0 °C and an average maximum temperature of 26.2 °C. The abundance peak of this A. albopictus population was identified from September to November. The positive effect of temperature on the seasonal activity of the adult population observed highlight the importance of climate change in affecting the occurrence, abundance, and distribution patterns of this species. The continuously monitoring activities currently ongoing point to an established population of A. albopictus in Loulé, Algarve, in a dispersion process to other regions of Portugal and raises concern for future outbreaks of mosquito-borne diseases associated with this invasive mosquito species.

[Congenital Heart Disease Prevalence in Portugal in 2015: Data from the National Register of Congenital Anomalies]. / Prevalência de Cardiopatias Congénitas em Portugal em 2015: Dados do Registo Nacional de Anomalias Congénitas.

INTRODUCTION: The prevalence at birth of congenital heart disease in Portugal is 8.3/1000 births; undetected critical congenital heart disease may result in adverse outcomes for the fetus/newborn infant. This study describes the reported cases of congenital heart disease in Portugal in 2015 regarding antenatal diagnosis, cardiac defect, and presence of other congenital anomalies/chromosomal abnormalities. These indicators are compared in live births and medical pregnancy terminations. Additionally, postnatal deaths were characterized. MATERIAL AND METHODS: Congenital heart disease data derived from the 2015 Portuguese National Registry of Congenital Birth Defects were analyzed. The prevalence rates per 1000 births were assessed by the chi-square test of independence. RESULTS: The prevalence of congenital heart disease in this study was 5/1000 live-births (339 live-births, 20% with critical defects). The most common defects were ventricular septal defect (38%), atrial septal defect (15%), aortic coarctation (7%), tetralogy of Fallot (7%) and pulmonary stenosis (5%). One third of the live births had antenatal diagnosis of congenital heart disease. In the live-births with critical congenital heart disease, 54% had antenatal diagnosis and 14% were diagnosed at birth. There were records of 84 pregnancy terminations; 49% had critical defects, 75% had non-cardiac congenital anomalies and 40% had chromosomal abnormalities. There were 15 postnatal deaths recorded (3.4% mortality rate), associated with prematurity/low birthweight, critical congenital heart disease, other non-cardiac congenital anomalies and chromosomal abnormalities. DISCUSSION: The data analysis revealed a prevalence of congenital heart disease in this study of 5/1000 births (inferior to other international studies), with a distribution per type of anomaly similar to that reported in previously published work. There were significant regional differences that need further studying. CONCLUSION: These results are paramount to characterize the Portuguese scenario and improve Healthcare planning. It is important to improve reporting in the Portuguese National Registry of Congenital Birth Defects.

Introdução: A prevalência de cardiopatias congénitas em Portugal é de 8,3/1000 nascimentos; cardiopatias congénitas críticas não detectadas podem resultar em graves consequências para o feto/recém-nascido. O objectivo deste trabalho é descrever os casos de cardiopatia congénita reportados em Portugal em 2015 quanto ao diagnóstico pré-natal, patologia cardíaca e à presença de outras malformações congénitas ou anomalias cromossómicas. Estas características são comparadas nos subgrupos dos nados-vivos e de interrupção médica da gravidez. Por último, caracterizam-se os óbitos.Material e Métodos: Os dados de cardiopatias congénitas reportadas ao Registo Nacional de Anomalias Congénitas em 2015 foram analisados, e calculadas as taxas de prevalência por 1000 nascimentos, comparadas utilizando teste de independência do quiquadrado.Resultados: A prevalência de cardiopatias congénitas neste estudo foi de 5/1000, (339 nados-vivos, 20% com cardiopatias congénitas críticas). As cardiopatias mais frequentes foram as seguintes: comunicação interventricular (38%), comunicação interauricular (15%), coartação da aorta (7%), tetralogia de Fallot (7%) e estenose pulmonar (5%). Um terço dos nados-vivos teve diagnostico pré-natal de cardiopatia. Dos nados-vivos com cardiopatias congénitas críticas, 54% teve diagnostico pré-natal e 14% foi diagnosticado ao nascer. Foram identificados 84 registos de interrupção médica da gravidez; 49% apresentava cardiopatias congénitas críticas, 75% outras malformações associadas, e 40% cromossomopatias. Foram registados 15 óbitos (3,4% de mortalidade) associados a prematuridade e/ou baixo-peso ao nascer, cardiopatias congénitas críticas, outras malformações e anomalias cromossómicas.Discussão: A prevalência de cardiopatias congénitas neste estudo (5/1000 nascimentos) foi inferior ao descrito noutros estudos internacionais, não obstante uma distribuição por tipo de anomalia semelhante ao previamente reportado. Observaram-se assimetrias regionais significativas que necessitam de mais investigação.Conclusão: Este estudo é relevante para melhor conhecimento da realidade nacional e organização dos Cuidados de Saúde. É importante uma maior adesão ao Registo Nacional de Anomalias Congénitas.

Ambient air pollution and lipid profile: Systematic review and meta-analysis.

Ambient air pollution (AAP) is recognized a cardiovascular risk factor and lipid profile dysregulation seems to be one of the potential mediators involved. However, results from epidemiologic research on the association between exposure to AAP and altered lipid profile have been inconsistent. This study aims to systematically review and meta-analyse epidemiologic evidence on the association between exposure to ambient air pollutants (particulate matter, nitrogen oxides, sulphur dioxide, ozone, carbon monoxide, back carbon) and lipid profile parameters (Total cholesterol; High-Density Lipoprotein Cholesterol; Low-Density Lipoprotein Cholesterol; TG-Triglycerides) or dyslipidaemia. Systematic electronic literature search was performed in PubMed, Web of Science and Scopus databases (last search on 24th May 2019) using keywords related to the exposure (ambient air pollutants) and to the outcomes (lipid profile parameters/dyslipidaemia). Qualitative and quantitative information of the studies were extracted and fixed or random-effects models were used to obtain a pooled effect estimate per each pollutant/outcome combination. 22 studies were qualitatively analysed and, from those, 3 studies were quantitatively analysed. Particulate matters were the most studied pollutants and a considerable heterogeneity in air pollution assessment methods and outcomes definitions was detected. Age, obesity related measures, tobacco consumption, sex and socioeconomic factors were the most frequent considered variables for confounding adjustment in the models. In a long-term exposure scenario, we found a 3.14% (1.36%-4.95%) increase in TG levels per 10 µg/m3 PM10 increment and a 4.24% (1.37%-7.19%) increase in TG levels per 10 µg/m3 NO2 increment. No significant associations were detected for the remaining pollutant/outcome combinations. Despite the few studies included in the meta-analysis, our study suggests some epidemiologic evidence supporting the association between PM10 and NO2 exposures and increased TG levels. Due to the very low level of evidence, more studies are needed to clarify the role of lipid profile dysregulation as a mediator on the AAP adverse cardiovascular effects.

A geographically weighted regression approach to investigate air pollution effect on lung cancer: A case study in Portugal.

The risk of developing lung cancer might to a certain extent be attributed to tobacco. Nevertheless, the role of air pollution, both form urban and industrial sources, needs to be addressed. Numerous studies have concluded that long-term exposure to air pollution is an important environmental risk factor for lung cancer mortality. Still, there are only a few studies on air pollution and lung cancer in Portugal and none addressing its spatial dimension. The goal was to determine the influence of air pollution and urbanization rate on lung cancer mortality. A geographically weighted regression (GWR) model was performed to evaluate the relation between particle matter10 (PM10) emissions and lung cancer mortality relative risk (RR) for males and females in Portugal between 2007 and 2011. RR was computed with the BYM model. For a more in-depth analysis, the urbanization rate and the percentage of industrial area in each municipality were added. GWR efforts led to identifying three variables that were statistically significant in explaining lung cancer relative risk mortality, PM10 emissions, urbanization rate and the percentage of industrial area with an adjusted R2 of 0,63 for men and 0,59 for women. A small set of 8 municipalities with high correlation values was also identified (local R2 above 0,70). Stronger relationships were found in the north-western part of mainland Portugal. The local R2 tends to be higher when the emissions of PM10 are joined by urbanization and industrial areas. However, when assessing the industrial areas alone, it was noted that its impact was lower overall. As one of the first communications on this subject in Portugal, we have identified municipalities where possible impacts of air pollution on lung cancer mortality RR are higher thereby highlighting the role of geography and spatial analysis in explaining the associations between a disease and its determinants.

The first Portuguese National Health Examination Survey (2015): design, planning and implementation.

BACKGROUND: In Health Examination Surveys interview information is complemented with objective information, providing more accurate indicators than self-reported data. We report the study design, planning and implementation of the first Portuguese Health Examination Survey (INSEF). METHODS: INSEF was a cross-sectional population-based study representative at regional and national level. Individuals aged between 25 and 74 years old, residing in Portugal were selected from the national health users' registry through multi-stage stratified probabilistic sampling. Sample size was set at 4200 individuals. Data was collected in primary care units and included blood pressure, height, weight, hip and waist measurements, blood collection for lipid profile, HbA1c and blood count and a general health questionnaire. European HES procedures were followed. RESULTS: A total of 4911 individuals agreed to participate (43.9% participation rate). Participation rate varied by region, sex and age group, being lower in Lisbon and Tagus Valley (32.8%), for men (41.8%) and for those aged 25-34 years old (36%). CONCLUSIONS: INSEF has set up an experienced national and regional structure for HES implementation. Nationally representative quality epidemiological data is now available for public health monitoring, planning and research.

The 1918-1919 Influenza Pandemic in Portugal: A Regional Analysis of Death Impact.

Although the impact of deaths occurring during the 1918-1919 influenza pandemic has been assessed in many archeo-epidemiologic studies, detailed estimates are not available for Portugal. We applied negative binomial models to monthly data on respiratory-related and all-cause deaths at the national and district levels from Portugal for 1916-1922. Influenza-related excess mortality was computed as the difference between observed and expected deaths. Poisson regression was used to estimate the association of geographic and sociodemographic factors with excess mortality. Two waves of pandemic influenza-July 1918 to January 1919 and April to May 1919-were identified, for which the excess all-cause death rate was 195.7 per 10,000 persons. All districts of Portugal were affected. The pandemic hit earlier in southeastern districts and the main cities, but excess mortality was highest in the northeast, in line with the high death burden experienced by northern Spanish provinces. During the period of intense excess mortality (fall/winter 1918-1919), population density was negatively associated with pandemic impact. This pattern changed during the March 1919 to June 1920 wave, when excess mortality increased with population density and in northern and western directions. Portuguese islands were less and later affected. Given the geographic heterogeneity evidenced in our study, subnational sociodemographic characteristics and connectivity should be integrated in pandemic preparedness plans.

The relevance of spatial aggregation level and of applied methods in the analysis of geographical distribution of cancer mortality in mainland Portugal (2009-2013).

BACKGROUND: Knowledge regarding the geographical distribution of diseases is essential in public health in order to define strategies to improve the health of populations and quality of life. The present study aims to establish a methodology to choose a suitable geographic aggregation level of data and an appropriated method which allow us to analyze disease spatial patterns in mainland Portugal, avoiding the "small numbers problem." Malignant cancer mortality data for 2009-2013 was used as a case study. METHODS: To achieve our aims, we used official data regarding the mortality by all malignant cancer, between 2009 and 2013, and the mainland Portuguese resident population in 2011. Three different spatial aggregation levels were applied: Nomenclature of Territorial Units for Statistics, level III (28 areas), municipalities (278 areas), and parishes (4050 areas). Standardized Mortality Ratio (SMR) and relative risk (RR) were computed with Besag, York and Mollié model (BYM) for the evaluation of geographic patterns of mortality data. We also estimated Global Moran's I, Local Moran's I, and posterior probability (PP) for the spatial cluster analysis. RESULTS: Our results show that the occurrence of lower and higher extreme values of the standardized mortality ratio tend to increase with the decrease of data spatial aggregation. In addition, the number of local clusters is higher at small spatial aggregation levels, although the area of each cluster is generally smaller. Regarding global clustering, data forms clusters at all considered levels. Relative risk (RR) computed by Besag, York and Mollié model, in turn, also shows different results at the municipalities and parishes levels. However, the difference is smaller than the difference obtained by SMR computation. This statement is supported by the coefficient variation values. CONCLUSIONS: Our findings show that the choice of spatial data aggregation level has high importance in the research results, as different aggregation levels can lead to distinct results. In terms of the case study, we conclude that for the period of 2009-2013, cancer mortality in mainland Portugal formed clusters. The most suitable applicable spatial scale and method seemed to be at the municipalities level and Besag, York and Mollié model, respectively. However, further studies should be conducted in order to provide greater support to these results.

Spatial epidemiology of cancer: a review of data sources, methods and risk factors.

Cancer is a major concern among chronic diseases today. Spatial epidemiology plays a relevant role in this matter and we present here a review of this subject, including a discussion of the literature in terms of the level of geographic data aggregation, risk factors and methods used to analyse the spatial distribution of patterns and spatial clusters. For this purpose, we performed a websearch in the Pubmed and Web of Science databases including studies published between 1979 and 2015. We found 180 papers from 63 journals and noted that spatial epidemiology of cancer has been addressed with more emphasis during the last decade with research based on data mostly extracted from cancer registries and official mortality statistics. In general, the research questions present in the reviewed papers can be classified into three different sets: i) analysis of spatial distribution of cancer and/or its temporal evolution; ii) risk factors; iii) development of data analysis methods and/or evaluation of results obtained from application of existing methods. This review is expected to help promote research in this area through the identification of relevant knowledge gaps. Cancer's spatial epidemiology represents an important concern, mainly for public health policies design aimed to minimise the impact of chronic disease in specific populations.

Epidemiological research on the incidence and prevalence of arterial hypertension in the Portuguese population: a scoping review.

INTRODUCTION AND OBJECTIVES: The Portuguese population is reported to have among the highest levels of mean blood pressure. The aim of the present study is to conduct a structured literature review describing the scope (quantity, focus and nature) of published epidemiological research on the prevalence and incidence of hypertension in the Portuguese population. METHODS: The scoping review was conducted during June 2013, using two information sources, B-on and PubMed, to search for published studies on the prevalence and incidence of hypertension with data collected between 2005-2013 and 1995-2013, respectively. RESULTS: We identified 527 publications: 14 on the prevalence and two on the incidence of hypertension. The results show more studies on populations in the North region of Portugal; an apparent lack of published studies specifically targeting the Alentejo and Algarve populations; long delays between data collection and publication of results (up to nine years); considerable variability in measurement methods; and infrequent data stratification by gender and age. CONCLUSIONS: Differences in blood pressure measurement methods, not specified in most studies, the infrequency of stratification of results by gender and age, and the geographic asymmetry in coverage of the Portuguese population, hinder monitoring of the incidence and prevalence of hypertension in Portugal.