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- The effect of air-conditioning (AC) on the in hospital mortality during the 2003 heat-wave in Mainland PortugalPublication . Nunes, Baltazar; Paixão, Eleonora; Dias, Carlos Matias; Nogueira, Paulo; Falcão, José MarinhoThe August 2003 heat-wave accounted for an excess of more than 1900 deaths in Portugal. At the European level it is acknowledged that this heat-wave was responsible for an excess of about 70000 deaths. In both situations a considerable number of deaths seem to have occurred in hospitals. The aim of this study was to evaluate the association between hospital existence of AC and the in hospital mortality rate during the 2003 heat-wave in Portugal mainland. A historic cohort design was used, including all patients with aged 45 or more, hospitalized during the last 7 days before the beginning of 2003’s heat-wave, and, therefore exposed to excess heat only in hospital. The study endpoint was the survival of patients in the 18 days of the heat-wave plus two days. This endpoint was compared between patients in services with air-conditioning (AC+) against patients in services without air-conditioning (AC-). Data was obtained from the National Hospital Discharge Database. Information on the air-conditioning existence was obtained by a survey of hospital administrations during 2007. The association between the survival of patients and being hospitalized in AC+ services was assessed with a Cox regression model that has included the covariates sex, age, hospital region, type of service, and main diagnosis at discharge as potential confounders. From all the hospitals of Portugal mainland 41 (54%) participated in the study (2093 patients). Statistical significant differences were found between patients hospitalized in AC+ versus AC- services. The hazard ratio of death for patients in AC+ services versus patients in AC- services was 0.60 (95% CI=0.37-0.97). Our study indicates that patients (<=45 years) hospitalized in a service AC+ were protected from the heat excess effect with a 40% risk reduction of death. These results support the recommendations of hospital acclimatization issued by the Portuguese Heat Wave Contingency Plan.
- A comparative description of the health status, the health determinants and health services use among the migrant population in Portugal. Data from the 4th national health interview survey (2004/2005)Publication . Dias, Carlos Matias; Paixão, Eleonora; Branco, Maria JoãoBackground: The 4th National Health Interview Survey (NHIS4) a general multipurpose survey of a probabilistic multi-stage sample of family households promoted by the Ministry of Health, conducted (2005/2006) by the National Institute of Health in partnership with the National Statistics Institute and the General Directorate of Health. Objective: Compare immigrants, returned emigrants and Portuguese residents on health status, health determinants, health services use. Methods: Data analysis from NHIS4. Age-standardized and gender stratified prevalences. Results: Data of 41 193 persons in family households in Portugal among which 1694 born outside Portugal and 3894 returned Portuguese-born emigrants were studied. A ‘good or very good’ perceived health status and quality of life was more frequent among immigrants. Smoking was more frequent among immigrants (men 27.7%; women 16.4%). Daily drinking high alcohol content drinks during the previous week was more frequent among returned Portuguese male emigrants (6.6%), than among immigrant (5.4%) or Portuguese never migrant men (5.1%). The National Health Service was mentioned by more than 80% of persons in all three populations both as ‘provider of health care’ and ‘more frequently used provider of health care’. Not using health care was more frequent among immigrant men (2.7%). No medical consultation during the previous 3 months was more frequent among immigrants (men 53.8%; women 46%). Four or more medical consultations during the same period was less frequent among immigrants (men 3.9%; women 6.4%). On average a lower proportion of immigrants reported a waiting time of more than 14 days for the last medical appointment. A ‘good or very good’ quality for the last medical appointment was more frequent in immigrants (89.8%) than Portuguese never migrants = 81.2%; returned Portuguese emigrants = 78.3%. Dental care use the previous year was higher in immigrant women (50.5%). Use of at least one contraceptive method was lower among immigrants (84.5%) than Portuguese never migrants (85.8%). Conclusions: Evidence of a healthy immigrant effect; no evidence of lower health care accessibility by immigrants and returned Portuguese emigrants have specific characteristics.
- Seasonal and pandemic patterns of Influenza in PortugalPublication . Gonçalves, Paulo; Nunes, Baltazar; Paixão, Eleonora; Cordeiro, Rita; Pechirra, Pedro; Conde, Patrícia; Arraiolos, Ana; Furtado, Cristina; Guiomar, RaquelThe National Influenza Reference Laboratory has been collecting data on influenza activity in Portugal since 1957 through the National Influenza Surveillance Programme, including information on clinical and virological characteristics of the disease, allowing the estimation of weekly incidence rates for influenza-like illness (ILI). This information has not only been used by the National Health Authorities for the management of the disease, in its several aspects, but has also been contributing to the study of influenza by the World Health Organisation. Particularly during the past decade, the world had been preparing for a long awaited influenza pandemic, which characteristics could not been foreseen but was feared to have potentially devastating consequences. In April 2009 a new strain of influenza A(H1N1) virus of swine origin disseminated throughout the world, resulting in the first pandemic of the XXI century. To face the increasing number of diagnosis being requested, a Network of Associated Laboratories dedicated exclusively to the diagnosis of the new influenza A(H1N1) pandemic virus was activated in our country. The data on influenza collected over the past two influenza seasons, through the National Influenza Surveillance Programme and the Network of Associated Laboratories, is presented and compared. 2. Materials and methods Over 3000 ILI cases were notified to the National Influenza Reference Laboratory and to the Department of Epidemiology of the National Institute of Health, in the context of the National Influenza Surveillance Programme, from week 38/2008 through week 20/2010. The distribution by age group, gender and region, and the signs and/or symptoms present were analysed. Nasopharyngeal swabs were collected for virological characterisation of influenza viruses circulating during this period. The intensity and duration of the epidemic periods were described based on the weekly incidence rates for ILI and as a function of a defined baseline. From week 17/2009 through week 20/2010, over 53.800 ILI cases and respective biological specimens were also notified and analysed by the Network of Associated Laboratories. 3. Results Seasonal AH1, AH3 and B influenza viruses circulating in Portugal during the 2008/2009 season were replaced by the new influenza A(H1N1) pandemic virus since the beginning of the pandemic in the country on week 17/2009. When considering the data obtained though the National Influenza Surveillance Programme, lower ILI incidence rates, lower percentage of confirmed influenza cases (particularly in the population over 15 years) and fewer symptoms presented at the time of notification were observed during the 2009/2010 pandemic. The large volume of cases analysed through the Network of Associated Laboratories is currently under evaluation and will be presented at a later stage. 4. Conclusions Facing the circulation of a new virus and the threat that this could impose to the population and to the health care system, the total number of ILI cases reported and analysed in our country during the 2009/2010 winter boosted to numbers not seen in previous influenza seasons. It is a fact that the 2009/2010 pandemic has had a significant impact in Portugal in many areas, such as the adoption of health-care regulations, availability of health-care facilities, vaccination strategies, and public action/awareness. However, in terms of pattern of disease, the data collected through the National Influenza Surveillance Programme may reveal a different reality. The data analysed suggests that the 2009/2010 pandemic was milder than the previous influenza seasons. Preliminary analysis of the data collected through the Network of Associated Laboratories appears to corroborate these findings.
- Using clinical criteria on seasonal and pandemic influenza: what to look for?Publication . Gonçalves, Paulo; Paixão, Eleonora; Machado, Ausenda; Cordeiro, Rita; Nunes, Baltazar; Pechirra, Pedro; Guiomar, RaquelThe reliability of clinical criteria on the diagnosis of influenza has been a question which has generated much debate in the scientific community. In Portugal, Influenza-like illness (ILI) cases have been notified by two sentinel networks, one of general practitioners (“Médicos-Sentinela”) and another of emergency rooms of hospitals and health centres, to the National Influenza Reference Laboratory in the context of the National Influenza Surveillance Programme, using clinical criteria adapted from the International Classification of Health Problems in Primary Care. With the emergence of a novel influenza A(H1N1) virus circulating in humans, the clinical definition of an influenza case was reformulated to accommodate the clinical features observed at that time. But how clinically different was the new variant A(H1N1) infection when compared to the seasonal influenza? In this study we propose to evaluate the signs and symptoms present in influenza cases diagnosed in Portugal during a seasonal influenza winter with those reported during the recent A(H1N1) pandemic. Also, we intend to evaluate the clinical criteria used for the notification of influenza cases during these two periods. 2. Materials and methods ILI cases were diagnosed for influenza at the National Influenza Reference Laboratory in the context of the National Influenza Surveillance Programme during the 2008/2009 influenza winter season and 2009/2010 pandemic period, from week 38/2008 through week 20/2010. Clinical information on those cases included the presence of signs and symptoms related with ILI as defined by the International Classification on Health Problems in Primary Care and on the case definition introduced by the European Commission Decision 202/253/EC (signs/symptoms analysed: sudden onset of symptoms, presence of fever, weakness, headache, myalgia, cough, sore throat, respiratory difficulty, chills and contact with an influenza patient). The odds ratio (OR) of being positive for influenza for each sign/symptom was calculated, independently and using multivariable logistic regression with all the signs/symptoms. Results were compared with the clinical definition of influenza used during both periods. 3. Results During the 2008/2009 winter, when seasonal influenza A(H3) viruses were dominant, all signs/symptoms analysed revealed an OR associated with a risk of being positive for influenza. Those with a higher risk were cough (OR 9.5, CI95% 4.7-19.3), fever (OR 4.5, CI95% 2.8-7.1), chills (OR 2.3, CI95% 1.5-3.5), myalgia (OR 1.7, CI95% 1.1-2-7) and contact with another ILI patient (OR 1.5, CI95% 1.1-2.0). Adjusting for all the signs/symptoms, the multivariable logistic regression reveals cough (OR 10.7, CI95% 5.2-22.0), fever (OR 5.1, CI95% 3.2-8.2) and contact with another patient (OR 1.4, CI95% 1.0-1.9) to be statistically significant. For the pandemic season 2009/2010, the signs/symptoms associated with a higher risk of being positive for influenza were fever (OR 4.5, CI95% 2.5-8.3), cough (OR 3.2, CI95% 2.1-4.8) and contact with another patient (OR 2.0, CI95% 1.4-2.8). Multivariable logistic regression also indicates these signs/symptoms to be statistically significant, after adjustment. 4. Conclusions Although initial evidences that the new influenza pandemic variant A(H1N1) could cause a clinically different infection, and fears that the disease would present a more severe profile than seasonal influenza, data collected in our country through the National Influenza surveillance Programme indicates that both situations were clinically similar in their presentation. This fact has been supported by studies from other countries.
- Evaluation of the seasonal vaccine coverage in Portugal: an overview of the last 12 yearsPublication . Nunes, Baltazar; Paixão, Eleonora; Branco, Maria JoãoInfluenza is an infectious disease responsible for seasonal epidemics affecting population worldwide. The vaccine is the main method for preventing flu and its more severe complications. For the past 12 years, the Department of Epidemiology of the National Institute of Health analyses the vaccine coverage in mainland Portugal. This study analyzes the evolution of the seasonal vaccine coverage since 1998-1999 untill 2009/2010. Also, we intend to characterize the practice of vaccination according to initiative, local, calendar and attitudes. We used a cross-sectional descriptive design based on a telephone interview survey conducted to households of the ECOS panel. This panel has 1078 households (approximately 3000 individuals), randomly selected, stratified by mainland regions (NUTsII) and contactable by landline and mobile phone. Results were weighted by number of households per region and according to sex and age population distribution. In season 1998/99 the vaccine coverage (VC) was 14.2 (CI95%: 11.6-16.8) and has been increasing progressively, reaching 20.4% (CI95%:18.3-22.6) in the last season (2009/2010). In the 2009/2010 season, as in others seasons, the elderly (VC=52.2%) and individuals with at least one chronicle condition (VC=37.4%) were the main contributors of this increase. Over the years, the initiative of vaccination belongs to the general practitioners and the health centres were most referred as the local of vaccination. The immunization period take place between October and November. In the last season, the main reason for non vaccination was related to mechanisms of devaluation/denial of the disease importance (45.7%). In the last season, the increase of the vaccine coverage may be attributable to the circulation of the pandemic virus. In general, the vaccine coverage has been high among the risk groups.
- Differential Diagnosis of Respiratory Viruses in Influenza-Like Illness: preliminary surveillance dataPublication . Gonçalves, Paulo; Pechirra, Pedro; Conde, Patrícia; Nunes, Baltazar; Guiomar, RaquelThe National Influenza Reference Laboratory (NIRL) coordinates and performs virological surveillance of Influenza-Like Ilness (ILI), integrated in the Portuguese National Influenza Surveillance Programme (NISP). Despite of this well established surveillance, little is known about the aetiology, virology and clinical aspects of respiratory illness in the country, other than that caused by influenza. National data shows that, during a winter influenza season, 40-70% of ILI cases are not attributed to influenza infection. This will have a significant impact on the estimation of influenza incidence, morbidity and mortality rates. Information on the contribution of other pathogens on the aetiology of ILI is, therefore, necessary. The objective of this preliminary study was to identify other respiratory viruses associated with influenza-like illness and their prevalence in Portugal. During the 2010/2011 influenza winter season, 1017 cases of influenza-like illness (according to the ICHPPC-II definition) were reported to the NIRL for influenza (FLU) diagnosis, in the context of the NISP. From these, 400 were selected to be additionally tested for other respiratory virus that cause respiratory illness with influenza-like symptoms, including respiratory syncytial virus (RSV) types A and B, human parainfluenza viruses (hPIV) types 1, 2 and 3, human rhinovirus (hRV) and adenovirus (AdV), by real-time PCR. Sample size was set in order to estimate the proportion ILI cases positive for other respiratory virus, considering an expected prevalence of 50% and an abosolute precison of 5% for the 95% confidence interval. The sample was selected with a random simple scheme using the package of statistcial programs SPSS. 22 cases were excluded from the study due to insufficient specimen. Infection with at least one virus was detected in 256 (67.7%) of the 378 ILI cases analysed, the most frequent of which (79.3%) were FLU viruses (43.0% FLU-A, 36.3% FLU-B) and hRV (11.3%). RSV, hPIV-2, hPIV-3 and AdV accounted for less than 8% frequency (3.1% RSV-A, 1.6% RSV-B, 1.2% hPIV-2, 0.4% hPIV-3 and 1.6% AdV). Co-infection of influenza with other respiratory virus was observed in 4 (1.6%) cases. The high frequency observed for FLU viruses was not unexpected since the recruitment of cases is, in this setting, biased towards the detection of influenza. Still, it is clear that multiple viruses co-circulate with influenza. Their influence on the clinical presentation of ILI will be further analysed.
- Influenza activity in Portugal - 2010/2011 seasonPublication . Gonçalves, Paulo; Machado, Ausenda; Nunes, Baltazar; Conde, Patrícia; Pechirra, Pedro; Guiomar, RaquelInfluenza activity in Portugal has been monitored since 1953 at the National Institute of Health. Clinical and virological data is analysed and ILI incidence rates are estimated weekly. Information is forwarded to National Health Authorities, contributing for the management of the disease. Since the 2009/2010 influenza pandemic, the National Influenza Surveillance Programme collects and integrates information generated through 3 surveillance structures, the Network of Sentinel Medical Practitioners (since 1990), the Network of Emergency Units (since 1999), and the Network of Laboratories for Influenza A(H1N1)2009 Diagnosis (since 2009). Together they provide a clearer picture of the influenza activity in the Country. Preliminary data (up to W18/2011) suggests that during the 2010/2011 winter season the influenza activity was moderate (max. 109.7 ILI cases/105 inhabitants on week 1/2011, provisory estimate), with an epidemic period of 11 weeks (W50/2010 to W8/2011). Influenza viruses type B/Vic were predominant at the beginning of the season but were gradually replaced by A(H1)2009 viruses, which became dominant from the middle of the season (W1/2011) onwards. Both types were antigenic and genetically similar to the vaccine strains. Type A(H3) and B/Yam viruses were also detected. Although the majority of ILI cases (53.7%) were from adults (15-44 years), the highest proportion (70.3%) of influenza cases was observed in children (5-14 years). Information on influenza vaccination with the 2010/2011 trivalent vaccine was available for 83.4% of cases. From those vaccinated (11.7%), the highest proportion (39.4%) of individuals were in the >65 years age group (7.1% were children up to 14 years) and 28.3% were positive for influenza. In terms of clinical presentation, fever and cough were the symptoms with the highest association with a positive laboratory diagnosis [OR 4.7 (2.7-8.1) and 3.9 (2.4-6.5), respectively], when all symptoms (according to ICHPPC-II definition) are considered independently. However, when influenza-type is considered, the odds ratio for fever is lower for type A than for type B [OR 2.9 (1.5-5.5) and 3.9 (1.7-9.0), respectively), and for cough is higher for type A than for type B [OR 4.9 (2.3-10.2) and 1.7 (0.9-3.0), respectively]. As expected, the pandemic A(H1)2009 virus has adopted a seasonal behaviour during the 2010/2011 season, co-circulating with influenza B. Influenza activity and clinical presentation were similar to previous seasons.
- Design and implementation of an epidemiological study for the characterization of potential pathway human exposure in a contaminated estuary environmentPublication . Dias, Carlos Matias; Machado, Ausenda; Paixão, Eleonora; Mateus, Inês; Joaquin, Toro; Caeiro, SandraIntroduction Sado River estuary is located in the west coast of Portugal. Previous environmental studies identified industrial contamination, non-point anthropogenic sources and contamination coming from the river, all promoting accumulation of polluted sediments with known impacts on the ecological system. Surrounding human populations have intense economic fishery activities. Together with agriculture, estuary fishing products are available to local residents. Food usage previously characterized through ethnographic studies suggests exposure to estuarine products, farming products, and water in daily activities, as potential routes of contamination. Few epidemiologic studies have been conducted to study associations of environmental contamination and health effects in Portugal. No epidemiological study has been identified in this particular geographical area. Objectives HERA project (Environmental Risk Assessment of a contaminated estuarine environment) is financed by the National Science Foundation (FCT- PTDC/SAU-ESA/100107/2008) and includes an epidemiological study aiming to characterize exposure pathways to estuarine products and its potential health effects. Materials and Method A cross-sectional comparative study of residents in Carrasqueira, a small riverside village in the south channel of the Sado Estuary, and residents in a second different population (Vila Nova de Mil Fontes-VNMF) 200 Km off Carrasqueira, selected as the non-exposed population. VNMF sits near another river estuary with similar fishing and agricultural activities but no known industrial or other contamination exposures. Simple random samples of 100 persons were selected in each study population from the National Health Service Lists. Questionnaire data collected at home (31 questions) intends to characterize: 1)Health effects: morbidity (diagnosed illnesses, medication), use of health services, reproductive history (pregnancies, abortions, congenital anomalies); 2) potential routes of exposure: socio-demographic, occupational (fishing and farming related occupations), leisure habits and hobbies (including recreational fishing), lifestyles (tobacco, alcohol); 3) Potential routes of human contamination from the estuary (including use of water, subsistence fishing and farming). Initial interviews with local residents and previous knowledge of the population’s habits elicited qualitative data about exposure characteristics used for questionnaire development. Questionnaires were applied at home by trained interviewers by face to face interviews of selected individuals (June and July 2011) using computed assisted personal interview (CAPI). All participants were included after a written informed consent. Results Participation rates were 62.5% in Carrasqueira and 48.3% in VNMF. Mean interview time is 50 minutes. Of selected Carrasqueira participants 58,3% were male (population=55,3%) and 60% were 20-59 in age. In VNMF, 44,2% were male (population=48,4%) the majority in the 20-59 age group (58,3%). Conclusions Planning and implementation of epidemiological studies on exposure, contamination routes and health effects of estuarine pollution should involve local Public Health professionals since early stages of planning and study design. Data collection and field work had no major drawbacks with a good response rate in the exposed population but lower in the comparison population. The summer time may explain lower than expected response rates especially in the comparison population.
- Facts related to the collection of biological samples in the National Health Examination Survey - Portuguese Component of the European Health Examination SurveyPublication . Silva, Marta Barreto da; Francisco, Vânia; Rasteiro, Paula; Sousa, Eduardo; Vicente, A.M.; Bourbon, Mafalda; Martins, Fátima; Seixas, Maria Teresa; Fernandes, Aida; Beleza, Álvaro; Mendonça, Francisco; Gil, Ana Paula; Dias, Carlos MatiasThe objective of the National Health Examination Survey (NHES), which corresponds to the Portuguese component of the European Health Examination Survey (EHES), is to collect health data, related risk factors and biological samples of the Portuguese population, using the EHES recommended methodology. These surveys involve an interview, clinical and physical measurements and blood collection. In this context, we herein describe the pilot study performed in S. Brás de Alportel in the Algarve region. For this pilot study, we have recruited 221 individuals (95 males and 126 females), between 25 and 91 years old, who were enrolled in the Health Centre of S. Brás de Alportel (Algarve). For each participant, we have collected 16.5 ml of total blood, in five different Vacutainer® tubes, which was later processed into serum, plasma and DNA. We have performed several biochemical analyses(total cholesterol, LDL,HDL, glucose, tryglicerides, creatinine, ALT, AST, -GT, CRP and iron) and a complete blood count. From the 221 participants in this pilot study, we were able to collect blood to 219 (99.5%). To 185 of these (84.5%) we were able to collect the total amount of blood. The biochemical analyses were performed in all the samples. The total blood count was performed in 103 samples (47%) due to transport constraints. We have also collected DNA from 210 participants (95.9%). We have created a biobank comprising 1847 serum aliquots and 959 plasma aliquots, which have been stored at - 80°C and 210 DNA aliquots which have been stored at 4°C. In conclusion, during this study, we have optimized the logistics and procedures to perform the large scale study for the NHES and EHES. In addition, we have created a biobank comprising detailed questionnaire data, physical and clinical data and biological samples from a representative sample of S. Brás de Alportel in Algarve, Portugal. This biobank will allow us to perform future studies, including the determination of the prevalence of gene variants of public health interest, the characterization of gene-environment interactions in the development of chronic diseases and the genetic structure of the Portuguese population. The success rate, the quality of the data and of the biological samples was high and comparable to similar studies.
- Influenza vaccine effectiveness 2010-11 in Portugal obtained by two methods: results from the EuroEVA studyPublication . Machado, Ausenda; Nunes, Baltazar; Pechirra, Pedro; Gonçalves, Paulo; Conde, Patricia; Guiomar, Raquel; Falcão, IsabelBackground: Every year the influenza vaccine is reformulated so estimating the influenza vaccine effectiveness (VE) every season and in an early stage is important to support public health decisions. Since 2008, Portugal has been participating in the I-MOVE (Influenza Monitoring Vaccine Effectiveness in Europe) project with the EuroEVA study, which main objective is to estimate seasonal and pandemic vaccine effectiveness during and after the influenza season. In this context, we used two methods to estimate VE for the 2010-11 seasonal influenza vaccine, both in the elderly and in all age groups. Methods: Two approaches were used to estimate VE: the Test Negative Design (TND) and the Screnning method (SM). For TND, laboratory-confirmed influenza cases (ILI+) were compared to laboratory-negative influenza ILI patients (ILI-). ILI cases were selected by general practitioners using systematic sampling. For SM, the vaccine coverage (VC) on the ILI+ cases (recruited from the TND) was compared to the VC estimated in the general population using a telephone survey (ECOS). Results: Overall results obtained by the EuroEVA study indicate that crude 2010-11 seasonal VE estimate was 79% (CI95% 43-94) and 70% (CI95% 32-87) for the TND and SM, respectively. After adjustment, the respective VE estimates decreased: 58 (CI95% -61-89) and 64% (CI95% 17-84). Conclusions: VE point estimates obtained by the two methods were very similar and an explanation for this consistency could be that the seasonal vaccine coverage estimates between ILI- (17.4%) and the population based telephone survey (17.5%) were also very close. Nevertheless, and due to small sample size, our study was unable to estimate VE for specific seasonal vaccine target groups. Further efforts should be done to increase sample size, mainly in the elderly population.