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- Using the social ecologic framework to improve the influenza vaccination strategy among the Portuguese elderlyPublication . Machado, Ausenda; Santos, Ana João; Kislaya, Irina; Larrauri, Amparo; Nunes, BaltazarBackground: In a context of lower than targeted influenza vaccination (IV) coverage, identifying factors associated IV uptake is essential to improve population coverage. Although extensive work has been done in this field, scarcer studies focused on framing these factors within a multifactorial model. Having the social ecological model (SEM) as framework, this study intended to identify and quantify the SEM levels associated to seasonal IV uptake in the Portuguese population aged 65 and more years. Methods: Data from the Portuguese 2014 National Health Survey was restricted to individuals aged 65 and more years (n=5669). The outcome of interest was self-reported IV uptake in the 2 years previous to the interview. Twenty three independent variables were selected from the survey and were allocated in one of the five SEM levels: individual, interpersonal, organizational, community and policy. Sex stratified and age adjusted analysis using Poisson regression were performed for each SEM level. To evaluate statistical significance and marginal contribution of each SEM level for explaining IV uptake, the full model was fitted (all variables from all 5 SEM levels). To determine joint statistical significance of variables of each SEM level, the model without respective SEM level was compared with the full model using likelihood ratio test. Additionally, marginal contribution of each SEM level was measured by relative reduction in magnitude of pseudo R square. Results: For both men and women, older age groups (85 or more vs 65-69 age group; PR=1.59 for men and PR=1.56 for women); having 3 or more chronic conditions (PR=1.39 for men and PR=1.35 for women); number of GP and outpatient visits in the previous 4 weeks were associated to higher IV uptake. For men, only 2 out of the 5 SEM levels were associated to IV uptake (individual and organizational). For women 3 levels were relevant for this preventive measure (individual, organizational and community). Main marginal contribution for explaining the IV uptake, came from individual (17.9% and 16.3%) and organizational (30.7% and 22.7%) levels for both men and women respectively. Conclusions: Besides individual characteristics, like age and health status - known determinants of IV uptake - this study highlights the importance of access and use of health care services for adoption of IV preventive measure. Moreover, it evidences a sex differential behaviour that should be accounted in the definition of the IV campaign strategy.
- Identification of risks and benefits associated to the consumption of raw milk: the first step of a risk-benefit assessmentPublication . Assunção, Ricardo; Pires, Sara; Nauta, MartenMilk is a highly nutritious food. Due to consumers’ perception that raw milk (RM) is a better source of nutrients and other active components there is currently considerable debate on the potential health benefits of consumption of RM compared to pasteurized milk (PM). Current trends advocating for “consuming natural” and “purchasing locally” have contributed to the increased popularity of RM in some countries (e.g. Italy, Estonia and the US). Claimed health benefits are e.g. “higher nutritional value”, especially in terms of vitamins’ contents, “beneficial microflora” as probiotic bacteria, and “allergy prevention”. However, several human pathogens can be present in RM and have been identified as the cause of several foodborne outbreaks. Consequently, this new trend encourages a proper assessment of the associated risks and benefits through a quantitative risk-benefit assessment (RBA). Traditionally, RBA considers as a first step the identification of the risks and the benefits posed by the considered food product, gathering scientific evidence for the inclusion or exclusion of each food component. This study aimed to identify the risks and the benefits associated to the consumption of RM when compared to PM. Through literature search, the nutritional, toxicological and microbiological food components that could be present in RM and PM were identified. For each identified food component, scientific evidence were analysed to support the decision about the inclusion or exclusion of each food component. Microbiological pathogens (Listeria monocytogenes, Salmonella spp., Campylobacter jejuni and Shiga toxin-producing Escherichia coli), probiotic bacteria (Lactobacillus spp.) and nutritional components (vitamins B2 and A) were identified, as well as the potential impact of RM in the reduction of the allergies’ prevalence. Since it is not expected that heat-treatment could affect the occurrence of chemical toxic compounds in milk, no toxicological components were identified in the assessment. We identified the main components that should be considered in RBA of RM consumption. Such a quantitative RBA will contribute to inform the consumers about the magnitude of the risk and the expected health impact.
- Raw drinking milk: when potential health benefits face the foodborne pathogens – a risk-benefit studyPublication . Assunção, Ricardo; Pires, Sara; Nauta, M.Introduction: Milk is a highly nutritious food, and currently there is a considerable debate on the potential health benefits of consumption of raw milk (RM) compared to pasteurized milk (PM). Claimed health benefits are e.g. “higher nutritional value”, especially regarding vitamins, “beneficial microflora” as probiotic bacteria, and “allergy prevention”. However, several human pathogens can be present in RM and have been identified as the cause of several foodborne outbreaks. Methodology: The objective of this study was to assess the risk-benefit balance and quantify the health impact of RM consumption in terms of Disability-adjusted life years (DALY). The microbiological hazards Listeria monocytogenes, Salmonella spp., Campylobacter jejuni and Shiga toxin-producing Escherichia coli were considered next to potentially beneficial components such as vitamins A and B2. Mathematical modeling, including predictive modeling of bacterial inactivation and growth, were used to quantify the DALYs associated to the consumption of RM directly from vending machines. Published data were used to perform exposure assessment (initial concentration and prevalence of pathogens, growth models of pathogens in milk according to different storage conditions), hazard characterization (dose-response models) and risk characterization (estimating the number of cases due to milk consumption). BCoDE was used to estimate the associated DALYs. Dutch food composition database was used to estimate the vitamins A and B2 intake through milk consumption. Modelling resources and GBD Results Tool were used to establish the associated risk prevention and to estimate the associated DALYs, respectively. Results: Despite the evidence for health benefits is limited and that the included pathogens do not reach high levels under proper storage, in extreme conditions (3 days under 8°C), 7.6 DALYs/year were estimated to be lost due to listeriosis. Still, preventable DALYs/year associated to vitamins would not exceed 1. Conclusions and Relevance: Quantification into DALYs will aid the public debate on the possible benefits and risks regarding the growing popularity of the consumption of RM. The added value of such a quantitative assessment is that consumers can be informed on the magnitude of the risk and the expected health impact. Special efforts are needed to control storage and to ensure the safety of RM.
- Não utilização de instrumentos estandardizados de avaliação cognitiva em crianças com paralisia cerebralPublication . Santos, Ana João; Folha, Teresa; Kislaya, Irina; Virella, DanielA paralisia cerebral (PC) é a deficiência motora mais comum na infância; a sua complexidade clínica pode dificultar a correta avaliação da capacidade funcional. A avaliação da cognição na paralisia cerebral permite adequar os apoios à criança, optimizando o seu potencial e inclusão socio-familiar. Exploraram-se factores associados à não utilização de instrumentos estandardizados na avaliação cognitiva das crianças com PC residentes em Portugal aos 5 anos de idade. O Programa de Vigilância Nacional da Paralisia Cerebral (PVNPC5A), desenvolve a vigilância activa de casos de PC em Portugal, na idade recomendada de 5 anos de idade, seguindo o protocolo comum da SCPE, que inclui a definição e classificação da PC, instrumentos de avaliação funcional, imagiológica e de morbilidade associada. Para os efeitos deste estudo, considerou-se a informação registada sobre a avaliação cognitiva como “avaliação clínica” e “avaliação por teste”. Foram estudados os casos de PC notificados ao PVNPC5A até setembro de 2018, nascidos em 2001-2010, residentes em Portugal na altura do registo. Foram exploradas associações bivariáveis entre a não-avaliação por teste” e factores socio-geográfico e factores clínicos e funcionais sexo, idade e escolaridade da mãe, migração, ano de nascimento, região, tipo clínico, inteligibilidade da fala, controlo da baba, motricidade global e bimanual, epilepsia ativa e défice visual. As variáveis de interesse foram objecto de análise multivariável de regressão logística. As associações foram estimadas pelo odds ratio (OR) com intervalo de confiança de 95% (IC95%). Foram estudadas 1719 crianças notificadas ao PVNPC. Apenas 1394 tinham informação sobre a avaliação cognitiva. Destas, foram alvo de avaliação cognitiva através de um teste estandardizado 27,3% (n=381). A distribuição de competência cognitiva foi de 46,6%(n=650) para défice grave; 14,5%(n=202) para défice moderado e 38,9%(n=542) sem défice. As crianças com “avaliação por teste” foram classificadas como com défice cognitivo grave (22,8%,n=87), com défice moderado (22,6%,n=86) e sem défice (54,6%,n=208); as com “avaliação clínica” foram classificadas como Na análise bivariável, associaram-se à não-avaliação por teste” a idade da mãe, a migração, a região, tipo clínico, a inteligibilidade da fala, controlo da baba, motricidade global e bimanual, a epilepsia ativa e défice visual. No modelo final obtido da análise multivariável observou-se que a possibilidade de não realização de avaliação cognitiva através de um teste estandardizado está associado à não inteligibilidade da fala (aOR=3,9;[2,9;5,4]), ao défice visual grave (aOR=2,8;[1,4;5,3]) e ao tipo de paralisia cerebral disquinético (aOR=2,8;[1,3;6,1]).A análise multivariável identificou como mais significativamente associados à possibilidade de "no-avaliação por teste”.A avaliação formal estandardizada da cognição a competência cognitiva não é feita em mais de 72% das crianças com PC. As características do tipo clinico, as competências de comunicação e visuais são determinantes para este resultado. É imprescindível que existam equipas com competências técnicas e recursos adequados para as necessidades de cada criança.
- Aplicação da Metodologia Seis Sigma na Avaliação dos Resultados Laboratoriais dos Parâmetros Ferro, Ferritina e TransferrinaPublication . Rodrigues, Ana Catarina de Oliveira; Requeijo, JoséOs distúrbios do Ferro estão entre as doenças mais comuns do metabolismo. Por se tratar de um sistema interligado, as alterações dos níveis séricos do Ferro influenciarão os níveis dos parâmetros Ferritina e Transferrina. Desta forma, o diagnóstico do metabolismo do Ferro no utente deve incluir um perfil hematológico completo com a inclusão dos parâmetros Ferritina e Transferrina. Desta maneira torna-se essencial assegurar que a determinação da concentração sérica através de exames laboratoriais seja precisa e exata. A variabilidade dos resultados interlaboratoriais, para o mesmo parâmetro em análise é um dos principais problemas de qualidade laboratorial, identificada através da participação em programas de avaliação externa da qualidade, que tem como principal objetivo assegurar a comparabilidade dos resultados entre laboratórios. A harmonização e normalização dos resultados entre laboratórios minimizam as diferenças e garantem a qualidade dos serviços prestados, na medida em que os tornam equivalentes. Esta dissertação tem como principal objetivo a implementação de ações de melhoria que permitam diminuir a variabilidade dos resultados laboratoriais referente à concentração das amostras, enviadas pelo Programa Nacional de Avaliação Externa da Qualidade (PNAEQ), relativamente aos parâmetros Ferro, Ferritina e Transferrina. De forma a atingir este objetivo e assegurar o desenvolvimento do projeto, utilizou-se a abordagem Seis Sigma como metodologia, métrica e sistema de gestão, através da aplicação do ciclo DMAIC (Define Measure Analyze Improve e Control), um método dinâmico que permite a melhoria dos processos em estudo pelo uso de diversas técnicas e ferramentas da qualidade. Após a avaliação e quantificação do nível de qualidade Sigma inicial, foram identificadas as causas da variabilidade interlaboratorial e implementadas ações de melhoria que levaram ao aumento do nível de qualidade Sigma em todos os parâmetros em estudo. O parâmetro Ferro obteve um nível de qualidade sigma final de 3,0 atingindo assim a meta proposta. Os parâmetros Ferritina e Transferrina obtiveram um nível final de qualidade sigma de 2,4 e 2,3. Consequentemente, de forma a manter a harmonização dos resultados laboratoriais ao longo do tempo, foi implementado um plano de controlo e monitorização que assegure a melhoria contínua dos ganhos obtidos.
- Toxicologia Genética: material de apoio a Estágio de Curta DuraçãoPublication . Louro, Henriqueta; Silva, Maria JoãoA Toxicologia Genética estuda os efeitos adversos de xenobióticos ao nível do genoma dos organismos vivos, procurando compreender a interação gene-ambiente e suas consequências para a saúde humana. Este estágio tem como objetivo introduzir os conceitos básicos e metodologias utilizadas na área da Toxicologia Genética, no contexto da Unidade de Investigação e Desenvolvimento do Departamento de Genética Humana do INSA.
- Evaluation of salt content in Portuguese hospital patient menusPublication . Nascimento, Ana; Santiago, Susana; Santos, Mariana; Castanheira, IsabelMeasures intended to reduce salt consumption are a Public Health priority, in order to address chronic diseases, related to excessive salt utilization. As patients totally rely on meals provided by Hospital caterings, Health institutions should provide nutritional well-balanced menus, in order to help patient’s recovery, to increase their quality of life and reduce the incidence of malnutrition and possible health complications, as cardiovascular diseases and hypertension specially related to excessive salt intake. The aim of this study was to evaluate sodium, and correspondent salt levels, in commonly served Hospital patient’s menus, and to evaluate if the amounts are in agreement with established salt recommendations. Samples of hospital’s meals (n=26) were collected between 2017 and 2019, and included soup, fruit, bread, salad and a composite dish, grinded all together and homogenised. These meals were mostly a general diet, intended to patients who do not require specific food modifications. Analyses were performed in quality management system, according to EN ISO 17025. Sodium levels were determined using an Inductively Coupled Plasma Optical Emission Spectroscopy (ICP-OES). Salt content, in g/100 g of food, was calculated by the formula: salt = sodium × 2.5. Sodium contents ranged from 69.0 to 303 mg/100g of food, and salt amounts from 0.2 to 0.8 g/100g of food. Meal portion size ranged from 500 to 900 g and salt levels from 2.0 to 5.0 g/meal. Taking into account the WHO recommendations of 5 g salt/day, the consumption of 100 g of a composite dish can represent about 30% of the daily salt intake. Also, salt consumption in Portugal almost doubles WHO recommended maximum level of intake, what is in agreement with presented results, where salt levels in one meal, generally covers recommendations for one day. As the prescription of inadequate diets and lack of flexibility of hospitals feeding service can contribute to patient’s malnutrition, early intervention in hospital diets is critical to prevent worsening of patients' nutrition status and can provide an opportunity to adopt healthy eating habits, what should include a salt reduction strategy.
- 3rd International Conference on Food Contaminants 'Challenges on Risk Assessment': Book of AbstractsPublication . Martins, Carla; Vasco, Elsa; Assunção, Ricardo; Alvito, PaulaICFC2019 Book of Abstracts
- Mycotoxins in adult population from Portugal: Overall results and determinants of exposurePublication . Vidal, Arnau; De Saeger, Sarah; Sarah, De Saeger; Nunes, Carla; Torres, D.; Goios, A.; Lopes, Carla; Assunção, Ricardo; Alvito, Paula; De Boevre, MartheHuman biomonitoring (HBM) is recognized as an important tool to assess the Human exposure to chemicals, contributing to describe trends and patterns of exposure over time and to identify population groups that could be under risk. Mycotoxins, fungi secondary metabolites that produce toxic effects in humans, are important compounds found in foods usually consumed worldwide in a daily basis. In Portugal, scarce data are available regarding exposure to mycotoxins and the determinants of this exposure. In the scope of the National Food, Nutrition, and Physical Activity Survey of the Portuguese General Population (2015-2016), 24h-urine samples from 94 participants were analyzed by liquid chromatography–mass spectrometry (LC-MS/MS) for the simultaneous determination of 37 urinary mycotoxins’ biomarkers and data obtained used to estimate the probable daily intake as well as the risk characterization applying the Hazard Quotient approach. Participants performed two face-to-face interviews and dietary intake was obtained by two non-consecutive 24-hours recalls with a time interval between 8 and 15 days, complemented with a Food Propensity Questionnaire. Results revealed the exposure of Portuguese population to zearalenone, deoxynivalenol, ochratoxin A, alternariol, citrinin and fumonisin B1 through the quantification in 24h urine and first-morning urine paired samples. Risk characterization data revealed a potential concern to some reported mycotoxins since the reference intake values were exceeded by some of the considered participants. The present study generated, for the first time and within a HBM study, reliable data on internal exposure to mycotoxins at individual level for the Portuguese population. These data were crucial to characterize the determinants of exposure and to support risk managers to establish preventive policy measures that contribute to ensure the public health protection.
- Interpretação dos resultados de ensaios microbiológicos em alimentos prontos para consumo e em superfícies do ambiente de produção e distribuição alimentar: valores-guiaPublication . Saraiva, Margarida; Correia, Cristina Belo; Cunha, Isabel Campos; Maia, Carla; Bonito, Conceição Costa; Furtado, Rosália; Calhau, Maria AntóniaAtravés da sua Unidade de Referência e do seu Laboratório de Microbiologia, o Departamento de Alimentação e Nutrição do INSA, cujas atividades se orientam para o conhecimento aprofundado da situação do país, no âmbito da segurança alimentar e nutrição, vem apresentar os valores-guia para a interpretação de resultados de ensaios microbiológicos em alimentos prontos para consumo e em superfícies do ambiente de produção e distribuição alimentar, que revê e atualiza os valores-guia por si estabelecidos em 2005, tendo em conta novos conhecimentos e alargando o seu âmbito. O documento agora publicado, abreviadamente, designado por ”Valores-guia INSA”, pretende ser um instrumento facilitador para a interpretação de resultados de ensaios microbiológicos nesta área, como métrica de gestão do risco, podendo ser utilizado para validar o desempenho de processos e o sistema de gestão da segurança alimentar implementado.