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- Vigilância Laboratorial da Tuberculose em Portugal: relatório 2025Publication . Laboratório Nacional de Referência de MicobactériasRelatório de Vigilância Laboratorial da Tuberculose em Portugal referente ao ano de 2025, elaborado pelo Laboratório Nacional de Referência de Micobactérias (LNR-TB) do Departamento de Doenças Infeciosas do INSA. O documento apresenta a análise da vigilância molecular das estirpes do complexo Mycobacterium tuberculosis (MTC), com base em dados acumulados desde 2020, incluindo a caracterização genómica e a identificação de relações filogenéticas relevantes para a deteção de cadeias de transmissão. Na sequência da implementação de metodologias baseadas em sequenciação do genoma total (WGS), o LNR-TB consolidou a sua capacidade para realizar, de forma sistemática, a caracterização genómica das estirpes de MTC. Esta abordagem permite a previsão do perfil de suscetibilidade aos antibacilares, incluindo de primeira linha, com elevado grau de fiabilidade, bem como a identificação precoce de eventos de transmissão. A utilização do WGS constitui, assim, uma ferramenta central para apoiar a decisão clínica e reforçar a resposta das Autoridades de Saúde, em linha com as recomendações europeias para países de baixa incidência de tuberculose. A vigilância laboratorial das micobactérias foi ainda alargada, incluindo de forma continuada a monitorização de Mycobacterium leprae, já integrada desde 2023, e, pela primeira vez, a caracterização de casos de micobactérias não tuberculosas (MNT), refletindo a crescente relevância destas infeções no contexto clínico e epidemiológico. Dos resultados apresentados no relatório, destacam-se os seguintes pontos: - A confirmação bacteriológica da tuberculose mantém-se essencial para a monitorização da doença e para a determinação do perfil de suscetibilidade aos antibacilares, devendo ser sempre complementada com exames laboratoriais adequados; - Os casos de tuberculose resistente à rifampicina ou multirresistente (TB-RR/MR) mantêm-se em vigilância, com variações anuais que justificam acompanhamento contínuo; - A distribuição geográfica dos casos evidencia maior concentração nas regiões de Lisboa e Vale do Tejo e do Norte, à semelhança do observado em anos anteriores; - A análise genómica permitiu identificar múltiplos clusters moleculares, incluindo cadeias de transmissão com persistência temporal, reforçando a importância da vigilância molecular contínua; - Desde 2023, que se confirmam anualmente casos de infeção por Mycobacterium leprae, todos com enquadramento epidemiológico compatível, evidenciando a importância da capacidade diagnóstica instalada; - A inclusão da vigilância das micobactérias não tuberculosas (MNT) constitui um avanço relevante, permitindo uma abordagem mais abrangente das infeções por micobactérias em Portugal; - Em alinhamento com as mais recentes recomendações europeias, nomeadamente do European Reference Laboratory Network for Tuberculosis (ERLTB-Net), está em curso a transição para a utilização sistemática da sequenciação do genoma total (WGS) em todos os isolados de Mycobacterium tuberculosis, com o objetivo de substituir progressivamente os testes fenotípicos de suscetibilidade aos antibacilares de primeira linha. Esta abordagem permitirá uma resposta diagnóstica mais rápida, integrada e preditiva, reforçando a eficiência do sistema e a qualidade da informação disponibilizada a clínicos e autoridades de saúde. Este relatório reforça o papel do INSA enquanto laboratório nacional de referência, evidenciando a importância da integração de ferramentas genómicas na vigilância laboratorial e no apoio à decisão clínica e em saúde pública.
- Variation in reporting of heatstroke mortality: evidence from a multi-country studyPublication . Tobias, Aurelio; Honda, Yasushi; Madaniyazi, Lina; Alhamad, Barrak; Lavigne, Erik; Roye, Dominic; Tong, Shilu; de Sousa Zanotti Stagliorio Coelho, Micheline; Huber, Veronica; Urban, Ales; das Neves Pereira da Silva, Susana; Achilleos, Souzana; Parks, Robbie M.; Iñiguez, Carmen; Masselot, Pierre; Vicedo-Cabrera, Ana M.; Armstrong, Ben; Gasparrini, Antonio; Hashizume, Masahiro; Multi-City Multi-Country Collaborative Research NetworkBackground: Heatstroke represents the most severe manifestation of heat exposure. Heatstroke is rare and under-reported, resulting in limited empirical data on its global incidence and burden. This study aimed to examine geographical variations and temporal trends in reported heatstroke mortality across multiple countries. Methods: We collected annual heatstroke mortality data from 34 countries participating in the Multi-Country Multi-City Collaborative Research Network between 2000 and 2022, using the ICD-10 code X30. Country-specific mortality rates were estimated using Poisson regression, alongside analyses of annual trends and associations with mean warm-season temperature. We also assessed the proportion of heatstroke deaths relative to both overall heat and extreme heat-attributable all-cause mortality. Findings: Heatstroke mortality rates varied widely across countries, with Japan reporting the highest rate (5·81 per 1 million population; 95% CI 4·43-7·62), followed by Cyprus (2·51; 1·36-4·61), and China (2·42; 1·21-4·85). By contrast, most countries in Europe, South America, and southeast Asia reported rates of less than one death per 1 million population. Heatstroke mortality increased over time in several countries and was associated with warm-season temperatures in most regions. The proportion of heatstroke deaths relative to overall heat-attributable mortality ranged from less than 1% in many countries to as close to 24% in Japan. When analyses were restricted to deaths attributable to extreme heat, the proportion of heatstroke deaths increased substantially. Interpretation: Our broad international assessment of heatstroke mortality highlights its distinct patterns compared with overall heat-attributable mortality. The observed variability likely reflects differences in recognition, reporting, and diagnostic practices, while climate exposure and health system capacity influence whether heat-related deaths are identified and recorded as heatstroke.
- Core Measure Set for Patient Safety in Perioperative Care: A Clinical Practice-Oriented Consensus StudyPublication . Nunes, Ana Beatriz; Teixeira, José Pedro; Leite, Andreia; Schäfer, Willemijn; Valli, Claudia; Martínez-Nicolas, Ismael; Paixão, Margarida; Seyfulayeva, Ayshe; Abelenda, Daniel Treviño; Rodríguez, Anna; Carvalho, Pedro Casaca; Heideveld-Chevalking, Anita; Emond, Yvette; Põlluste, Kaja; Calsbeek, Hiske; Arnal-Velasco, Daniel; Žaludek, Adam; Garel, Pascal; Wagner, Cordula; Groene, Oliver; Orrego, Carola; Sousa, Paulo; SAFEST Scientific Advisory Group; SAFEST Scientific Executive Group; SAFEST ConsortiumObjectives: To develop a consensus-based EU-wide Core Measure Set (CMS), including patient-reported measures, for evaluating perioperative patient safety in routine adult care. Methods: A four-phase approach was applied: 1) identification of candidate structure, process, and outcome measures through three literature reviews; 2) synthesis into an initial list via deduplication and merging; 3) consensus process using a two-round modified eDelphi technique, with subject-matter and lived-experienced experts rating the importance and feasibility of each measure (consensus: ≥75% rating 7–9, ≤15% rating 1–3), followed by an online Consensus Conference addressing measures highly valued by patients but lacking feasibility consensus; 4) refinement of the CMS for patient safety in perioperative care (CMS-PSPC). Results: Out of 9,717 records identified, 340 studies were included, yielding 1,305 measures. After refinement, 247 measures were consolidated; 84 reached consensus, and ten more were added via the Consensus Conference. The final CMS-PSPC comprised 76 measures: 22 outcome, 18 process, and 36 structure measures. Conclusion: The CMS-PSPC provides a standardised, patient-centred framework for evaluating, monitoring and benchmarking perioperative patient safety in routine clinical care, supporting EU-wide quality improvement efforts.
- Dietary exposure to essential and toxic trace elements in the portuguese population: A total diet study approachPublication . Ventura, Marta; Rego, Andreia; Gueifão, Sandra; Delgado, Inês; Coelho, InêsThe World Health Organization (WHO) and the European Food Safety Authority (EFSA) recognise Total Diet Studies (TDS) as an essential public health tool for assessing dietary exposure to beneficial and harmful substances through food. This study provides occurrence data for nine trace elements (As, Cd, Co, I, Mo, Pb, Se, Sn, and Sr) in representative foods consumed by the Portuguese population, using a harmonised TDS methodology. The study also fills previously missing data in the Portuguese Food Composition Database, strengthening its value for nutritional monitoring and exposure assessment. The results show that the lowest concentration of all trace elements were observed in the “Water and water-based beverages” group while the highest concentrations were found in “Fish, seafood, amphibians, reptiles, and invertebrates” (As, Cd, I, Pb, Se, Sr), “Sugar confectionery and water-based sweet desserts” (Co), “Legumes, nuts, oilseeds and spices” (Mo), and “Fruit and fruit products” (Sn). Importantly, all measured levels of trace elements were below the applicable legal limits, indicating that the analysed foods do not pose a risk for consumer health. Furthermore, the data can support risk assessment, regulatory decisions, and the development of public health policies related to trace element intake. These findings also facilitate comparisons with international TDS data, contributing to global understanding of dietary exposures.
- Vaccine effectiveness against medically attended, laboratory-confirmed influenza in the I-MOVE primary care network in Europe, VEBIS project, 2024/25Publication . Lucaccioni, Héloïse; Pozo, Francisco; Pérez-Gimeno, Gloria; Dürrwald, Ralf; Uras, Marina; Domegan, Lisa; Oroszi, Beatrix; Meijer, Adam; Trobajo-Sanmartín, Camino; Ujvari, Dorina; Rodrigues, Ana Paula; Mlinarić, Ivan; Lazar, Mihaela; Rivas Wagner, Eva; Erdwiens, Annika; Enouf, Vincent; McKenna, Adele; Túri, Gergő; de Lange, Marit; Martínez-Baz, Iván; Latorre-Margalef, Neus; Guiomar, Raquel; Kurečić Filipovic, Sanja; Dinu, Sorin; Mokoroa, Olatz; Tolksdorf, Kristin; Masse, Shirley; Bennett, Charlene; Kristóf, Katalin; Hooiveld, Mariette; Castilla, Jesús; Santos Almeida, João; Višekruna Vučina, Vesna; Popescu, Rodica; Bacci, Sabrina; Kaczmarek, Marlena; Kissling, EstherBackground: We conducted a multicenter test-negative study to estimate vaccine effectiveness (VE) against medically attended, laboratory-confirmed influenza in primary care, Europe, 2024/25. Research design and methods: Specimens were collected from patients with acute respiratory infection. All or a random sample of viruses were sequenced. VE was (1-odds ratio) × 100, adjusted for confounders. Results: We included 7275 cases and 17,516 controls (weeks 40-2024-18-2025). The overall VE was 46% (95% CI: 40-52), lowest in adults ≥65 years at 28% (95% CI: 12-42). VE against influenza A(H1N1)pdm09 was 30% (95% CI: 19-40); ranging 16-34% by age and vaccination target group. Most (88%) circulating clades were 5a.2a, distinct from the vaccine clade. VE was 28% (95% CI: 7-45) against 5a.2a (C.1.9), and 6% (95% CI: -62-45) against the vaccine-matched clade 5a.2a.1 (D). VE against influenza A(H3N2) was 38% (95% CI: 26-49); ranging 20-66% by age and target group. Circulating viruses belonged to the vaccine clade 2a.3a.1, with 88% subclade (J.2). VE against influenza B was 76% (95% CI: 69-81); ranging 70-80% by age and target group; all viruses belonged to the vaccine clade V1A.3a.2, with diverse subclades. Conclusions: Influenza vaccination protected approximately one in two vaccinated individuals against medically attended infection in primary care in Europe, 2024/25, varying by (sub)type and age.
- Genomic evolution and re-emergence of a multidrug-resistant Clostridioides difficile RT027 clone with reduced vancomycin susceptibility driving a prolonged hospital outbreakPublication . Isidro, Joana; Dionísio, Filipa; Alves, Frederico; Almeida, Soraia; Santos, Cláudia; Santos, Manuel Mota; Reis, Ernestina; Oliveira, Júlio R.; Gomes, João Paulo; Oleastro, MónicaFollowing an extended period of declining prevalence of the epidemic Clostridioides difficile ribotype 027 (RT027) in Portugal, a genetically distinct, multidrug-resistant (MDR) RT027 strain with reduced susceptibility to vancomycin has emerged, causing a 15-month outbreak. This investigation provides epidemiological and genomic evidence for renewed circulation and evolutionary adaptation of this high-risk lineage. A comprehensive outbreak investigation was conducted in a tertiary-care hospital in northern Portugal between 2023 and 2025. Epidemiological and clinical data, antimicrobial exposures, and infection-control measures were analysed. Whole-genome sequencing (WGS) was performed to characterize the outbreak clone. Sixty-six RT027 C. difficile infection (CDI) cases were confirmed, with incidence peaking at 5.46 cases per 10,000 patient-bed days in April 2024. WGS revealed an unusual accumulation of AMR determinants conferring a broad MDR phenotype. Notably, all isolates harboured the VanR T115A substitution, a rare mutation previously linked to reduced vancomycin susceptibility, raising concerns regarding evolving antimicrobial tolerance within RT027. The close relatedness to 2016-2018 USA isolates suggests a recent emergence of this clone. Transmission was facilitated by structural constraints, limited isolation capacity and shared sanitary facilities. This prolonged outbreak documents the re-emergence and genomic evolution of a hypervirulent RT027 lineage, characterized by a concerning expansion of antimicrobial resistance and decreased vancomycin susceptibility and a high recurrence rate (25%). These findings highlight the ongoing adaptive potential of C. difficile under antimicrobial pressure and underscore the need for strengthened surveillance, genomic monitoring, and infection-prevention strategies to mitigate re-establishment of epidemic RT027 strains in Europe and beyond.
- Predicted no effect concentrations of antifungals for wastewater management and agricultural usePublication . Gil, D.; José, S.; Ascenso, A.; Babič, M. Novak; Segal, E.; Meletiadis, J.; Gangneux, J.P.; Weiskerger, C.J.; Solo-Gabriele, H.M.; Valério, E.; Brandão, J.Antifungal resistance is an on-growing public health concern due to the difficulty in managing or treating medical conditions that often favour fatal fungal infections. The changing climate and globalisation, which increase fungal persistence and propagation, adds to that concern. Wastewater disposal is one potential source to the environment as antifungals are released into it. Considering that most fungal infections originate from the environment and considering the One Health principle, introducing antifungals through wastewater effluents has the potential to promote the emergence and dissemination of antifungal resistance. The objective of this study was to generate knowledge that can assist regulating the release of antifungals in the environment by quantifying predicted no-effect concentrations (PNECs) that would not promote antifungal resistance. For this purpose, a systematic review was performed to consolidate information on antifungals released to the environment and respective concentrations. The systematic literature review followed Preferred Reporting Items for Systematic literature reviews and Meta Analyses extension for Scoping Reviews (PRISMA-SLR). The analysis of 122 reviewed articles using this approach showed high concentrations and dispersion of antifungals in water, wastewater or soil. This highlights their potential dispersion in the environment, thus increasing the potential of fungal antimicrobial resistance. Due to the lack of PNEC values using fungi as model organisms in this review, PNECs for 17 antifungals were calculated using as model, as it is done for clinical purposes. We consider that the antifungal PNECs calculated and consolidated from the literature can be used to prioritise them for regulation and to determine acceptable levels in wastewater effluents.
- When disinfection fails: Biocide tolerance as a driver of campylobacter persistence and resistancePublication . Fonseca, Inês M.; Martins, Inês; Oleastro, Mónica; Ferreira, SusanaCampylobacter spp. constitutes a significant global public health hazard as it is a leading cause of reported foodborne diseases. Human infection is predominantly acquired through the ingestion of contaminated food, unpasteurized milk and untreated water, prompting the widespread implementation of chemical disinfection across several sectors, from healthcare, domestic environments, and food-processing to animal husbandry. While these biocidal agents encompass multiples classes with different modes of action and efficacy, growing evidence suggests that their extensive and repeated use may unintentionally promote bacterial persistence, tolerance and adaptive responses. Although biocide resistance has been documented in several foodborne pathogens, data on biocide tolerance in Campylobacter spp. remain limited. Available studies report variable degrees of reduced susceptibility to commonly used biocides among isolates originating from poultry production, food-processing environments, and water systems. Importantly, while biocide-induced adaptive responses in Campylobacter spp. may potentially overlap with antimicrobial resistance mechanisms, the extent to which these agents drive co-selection, persistence, or dissemination requires further elucidation. Evidence remains limited on the effects of long-term and repeated exposure under realistic processing conditions, the interplay between stress-induced gene regulation and stable genetic changes, and the contribution of mobile genetic elements, biofilm formation, and microbial communities in shaping antimicrobial resistance evolution. In light of the global health burden imposed by campylobacteriosis and the rising challenge of antimicrobial-resistant Campylobacter, this review brings together current evidence on the role of biocides in shaping bacterial survival, adaptation, and resistance mechanisms.