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- The potential bias introduced into COVID-19 vaccine effectiveness studies at primary care level due to the availability of SARS-CoV-2 tests in the general populationPublication . Lanièce Delaunay, Charlotte; Nunes, Baltazar; Monge, Susana; de Lange, Marit; Túri, Gergő; Machado, Ausenda; Latorre-Margalef, Neus; Mlinarić, Ivan; Lazar, Mihaela; Botella Rocamora, Paloma; Erdwiens, Annika; Sève, Noémie; Domegan, Lisa; Martínez-Baz, Iván; Hooiveld, Mariëtte; Oroszi, Beatrix; Guiomar, Raquel; Sperk, Maike; Kurečić Filipović, Sanja; Pascu, Catalina; Linares Dopido, Juan Antonio; Dürrwald, Ralf; Rameix-Welti, Marie-Anne; McKenna, Adele; Castilla, Jesús; van Hagen, Cheyenne; Knol, Mirjam; Bacci, Sabrina; Kaczmarek, Marlena; Kissling, Esther; VEBIS Primary Care Vaccine Effectiveness GroupBackground: With SARS-CoV-2 self-tests, persons with acute respiratory infections (ARI) can know their COVID-19 status. This may alter their decision to consult a general practitioner (GP), potentially biasing COVID-19 vaccine effectiveness (VE) studies. We explore bias mechanisms, simulate magnitude, and verify control methods. Methods: We used directed acyclic graphs (DAGs) to illustrate the bias mechanisms. Based on the European primary care VEBIS multicentre test-negative design (TND) study, we simulated populations with varying true VE (20%-60%), proportions of persons with ARI self-testing (10%-30%), effect of COVID-19 vaccination on self-testing (1.5-2.5), and effect of self-test result on GP consultation (0.5-2). We performed 5000 runs per scenario, estimating VE among those consulting a GP. We calculated bias as true VE minus mean simulated VE, unadjusted and adjusted for self-testing, using logistic regression. Results: DAGs suggested collider stratification bias if vaccination had an effect on self-testing and if self-test results affected GP consultation. Bias was -12% to 18% at 20% true VE, with the most extreme associations and 30% self-testing. With 60% true VE and 10%-20% self-testing, bias was lower. Bias was higher (-18% to 45%) if both positive and negative self-test results affected GP consultation. Adjusting for self-testing removed the bias. Conclusions: Self-testing may bias COVID-19 VE TND studies in primary care if self-testing is high, particularly with low VE. We recommend primary care TND VE studies collect self-testing information to eliminate potential bias. Observational studies are needed to understand the relationship between vaccination, self-testing, and GP consultation, in these studies' source population.
- Description and comparison of national surveillance systems and response measures for Aedes-borne diseases in France, Italy and Portugal: a benchmarking study, 2023Publication . Fotakis, Emmanouil Alexandros; Grau-Pujol, Berta; Kelly, David; Leite, Pedro Pinto; Martins, João Vieira; Alves, Maria João; Di Luca, Marco; Venturi, Giulietta; Ferraro, Federica; Franke, Florian; Pietin, Clément; Calba, Clémentine; Charles, Tanja; Riccardo, Flavia; Vasconcelos, Paula; Ramalli, LaurianeBackground: Regions of southern Europe are increasingly colonised by Aedes albopictus, with incidence of autochthonous dengue cases rising in recent years.AimWe describe and compare Aedes-borne disease (dengue, chikungunya and Zika) incidence from 2017 to 2023, and the surveillance systems and response measures operating in France, Italy and Portugal in 2023, to improve surveillance, prevention, preparedness and response in Europe.MethodsWe performed a benchmarking analysis to systematically capture the systems used in each country. We collected data from key-informant interviews, national guidelines, reports and scientific literature using a standardised questionnaire adapted from the European Centre for Disease Prevention and Control framework.ResultsAll three countries have an integrated surveillance system for Aedes-borne diseases and share similarities in surveillance type, geographic coverage and case definitions. Differences entail mainly event-based and active surveillance activities. Geographic coverage of vector surveillance is national in France and Portugal but regional in Italy. In response to autochthonous transmission, all countries implement/foresee active case-finding and blood safety protocols, while France and Italy strongly rely on vector control. Upon vector detection in non-colonised areas, the three countries implement ad hoc entomological surveillance and vector control.ConclusionsSurveillance systems and response measures in France, Italy and Portugal are broadly similar, with variations reflecting differences in healthcare system organisation (centralised in Portugal and France, regionalised in Italy), Ae. albopictus distribution and local transmission of Aedes-borne diseases. Risk-based surveillance, considering the national and cross-border epidemiological and entomological situations, can strengthen preparedness and early warning for Aedes-borne diseases in Europe.
- Relative effectiveness of the second booster COVID-19 vaccines against laboratory confirmed SARS-CoV-2 infection in healthcare workers: VEBIS HCW VE cohort study (1 October 2022-2 May 2023)Publication . Savulescu, Camelia; Prats-Uribe, Albert; Brolin, Kim; Uusküla, Anneli; Bergin, Colm; Fleming, Catherine; Zvirbulis, Viesturs; Zavadska, Dace; Szułdrzyński, Konstanty; Gaio, Vânia; Popescu, Corneliu Petru; Craiu, Mihai; Cisneros, Maria; Latorre-Millán, Miriam; Lohur, Liis; McGrath, Jonathan; Ferguson, Lauren; Abolina, Ilze; Gravele, Dagne; Machado, Ausenda; Florescu, Simin Aysel; Lazar, Mihaela; Subirats, Pilar; Clusa Cuesta, Laura; Sui, Jacklyn; Kenny, Claire; Krievins, Dainis; Barzdina, Elza Anna; Melo, Aryse; Kosa, Alma Gabriela; Miron, Victor Daniel; Muñoz-Almagro, Carmen; Milagro, Ana María; Bacci, Sabrina; Kramarz, Piotr; Nardone, Anthony; VEBIS HCW Study GroupIntroduction: Repeated COVID-19 booster vaccination was recommended in healthcare workers (HCWs) to maintain protection. We measured the relative vaccine effectiveness (rVE) of the second booster dose of COVID-19 vaccine compared to the first booster, against laboratory-confirmed SARS-CoV-2 infection in HCWs. Methods: In a prospective cohort study among HCWs from 12 European hospitals, we collected nasopharyngeal or saliva samples at enrolment and during weekly/fortnightly follow-up between October 2022 and May 2023. We estimated rVE of the second versus first COVID-19 vaccine booster dose against SARS-CoV-2 infection, overall, by time since second booster and restricted to the bivalent vaccines only. Using Cox regression, we calculated the rVE as (1-hazard ratio)*100, adjusting for hospital, age, sex, prior SARS-CoV-2 infection and at least one underlying condition. Results: Among the 979 included HCWs eligible for a second booster vaccination, 392 (40 %) received it and 192 (20 %) presented an infection during the study period. The rVE of the second versus first booster dose was -5 % (95 %CI: -46; 25) overall, 3 % (-46; 36) in the 7-89 days after receiving the second booster dose. The rVE was 11 % (-43; 45) when restricted to the use of bivalent vaccines only. Conclusion: The bivalent COVID-19 could have reduced the risk of SARS-CoV-2 infection among HCWs by 11 %. However, we note the limitation of imprecise rVE estimates due to the proportion of monovalent vaccine used in the study, the small sample size and the study being conducted during the predominant circulation of XBB.1.5 sub-lineage. COVID-19 vaccine effectiveness studies in HCWs can provide important evidence to inform the optimal timing and the use of updated COVID-19 vaccines.
- Prevalence of T. rubrum and T. interdigitale Exhibiting High MICs to Terbinafine in Clinical Samples Analyzed in the Portuguese Mycology Reference LaboratoryPublication . Schirmer, Helena; Henriques, Camila; Simões, Helena; Veríssimo, Cristina; Sabino, RaquelCutaneous fungal infections represent a significant burden worldwide with a high impact on public health. Accurate identification of dermatophyte species causing these infections is vital for an appropriate treatment. Terbinafine is the primary agent against Trichophyton species due to its clinical efficacy; however, cases of elevated minimum inhibitory concentration (MIC) have been reported, raising clinical and epidemiological concerns. Herein, we aimed to detect Trichophyton rubrum and Trichophyton interdigitale isolates collected from clinical samples with terbinafine-high MICs (TRB-hMIC). A total of 168 isolates, recovered from 2017 to 2023, were identified as T. rubrum complex (140/83.4%) or T. interdigitale (28/16.7%) and further screened regarding their terbinafine susceptibility. Four isolates with capacity to grow in terbinafine media were detected by screening, and these and a further sixteen random isolates were submitted to the broth microdilution method. This methodology confirmed the four (2.4%) isolates as TRB-hMIC. One T. rubrum and three T. interdigitale showed a minimum inhibitory concentration (MIC) higher than 1 mg/L. Partial sequencing of the SQLE gene identified point mutations in T. rubrum (Phe397Iso) and in one T. interdigitale (Phe397Leu) isolate. Notably, in the other two T. interdigitale isolates with TRB-hMIC, no point mutations in the SQLE gene were identified. In conclusion, TRB-hMIC isolates (T. rubrum and T. interdigitale) were identified in clinical samples analyzed in Portugal, as antifungal susceptibility testing is a crucial routine for identifying treatment failures and also for epidemiological purposes aiming to monitor the dynamics of terbinafine resistance.
- SOLARIS project: a portable 3D-printed bioaerosol sampler for environmental bacterial collectionPublication . Dobroes Fonseca, Pedro Henrique; Duarte, Filipe Miguel Borgas Henriques; Alves, Frederico Silva de Sousa; Borges, Jose Alberto de Jesus; Cardoso, Susana Isabel Pinheiro; Silverio, Vania Cristina Henriques; Antunes, Wilson David TalhaoBioaerosols, a subset of aerosols released from the biosphere, can carry pathogens, and include particles with diameters from nanometres to a few micrometres. They can remain suspended indoors and travel significant distances. Bioaerosol studies play a vital role in public health, as bioaerosols are an effective route for human and animal pathogen transmission, especially in animal production and handling facilities, which are considered hotspots for the emergence of zoonotic pathogens. The 'One Health' approach, which interconnects human, animal and environmental health, underscores the need for robust biomonitoring and biosurveillance systems. We introduce the SOLARIS project, a novel bioaerosol sampler manufactured through three-dimensional printing with a biocompatible material. Our sampler is compact, portable and uses a liquid collection medium, increasing bioefficiency. Our sampler's laboratory testing demonstrated the successful separation of viable bacteria from artificially generated bioaerosols. Collected samples were found suitable for downstream analysis methods such as culturing, mass spectrometry, molecular detection and electron microscopy. A field trial at a swine facility was performed, in which spores were successfully collected from bioaerosols and identified using microbiological and molecular methods, reinforcing our sampler's utility and emphasizing the significance of incorporating aerosol samples in research studies within the One Health approach.
- Painless but Visible: The Case Report of a Painless Facial Nodule in a ChildPublication . Vieitez-Frade, Joana; de Sousa, Diogo; Patrocínio, João; Gargaté, Maria João; Jesus, Miguel; Duarte, Cristina; Tapadinhas, CristinaNo abstract available
- Systematic review and modelling of seroprevalence in humans, Europe, 2000 to 2021Publication . Friesema, Ingrid Hm; Waap, Helga; Swart, Arno; Györke, Adriana; Le Roux, Delphine; Evangelista, Francisco Md; Spano, Furio; Schares, Gereon; Deksne, Gunita; Gargaté, Maria João; Calero-Bernal, Rafael; Jokelainen, Pikka; Seeber, Frank; Sroka, Jacek; Lundén, Anna; van den Berg, Oda; Jore, Solveig; Wisselink, Henk J.; Dámek, Filip; Vestergaard, Lasse S.; Opsteegh, Marieke; APAGARBackground: Toxoplasma gondii is a zoonotic protozoan capable of infecting warm-blooded animal species and humans. Although toxoplasmosis presents mostly as mild or asymptomatic infection in immunocompetent individuals, in unborn children and people with weakened immune systems, the disease can be severe with ocular, neurological or multi-systemic manifestations and even death. Aim: We aimed to collate and analyse data on T. gondii seroprevalence in humans to model and compare age-dependent prevalence in geographic regions in Europe. Methods: A systematic review identified 1,822 scientific publications, from which seroprevalence data were extracted from 69 studies. Data were analysed using a Bayesian hierarchical model. Results: The modelling of the seroprevalence indicated the highest incidence rates in eastern (50%) and western (48%) Europe, with the lowest estimates in northern Europe (18%) and the United Kingdom (UK) (18%). Eastern and western Europe were regions where T. gondii infections occurred earliest in life, with half of the population expected to be seropositive by the age of 44 and 47 years, respectively. In contrast, in northern Europe and the UK the modelled median time to infection exceeded 170 years. Conclusions: Results of the study provide a robust baseline for future epidemiological research on human T. gondii infections in Europe and may be useful to validate subsequent research, such as risk assessment studies.
- Detection of Echinococcus spp. and other taeniid species in lettuces and berries: Two international multicenter studies from the MEmE projectPublication . Umhang, Gérald; Bastien, Fanny; Cartet, Alexandra; Ahmad, Haroon; van der Ark, Kees; Berg, Rebecca; Bonelli, Piero; Davidson, Rebecca K.; Deplazes, Peter; Deksne, Gunita; Gargate, Maria João; Van der Giessen, Joke; Jamil, Naila; Jokelainen, Pikka; Karamon, Jacek; M'Rad, Selim; Maksimov, Pavlo; Oudni-M'Rad, Myriam; Muchaamba, Gillian; Oksanen, Antti; Pepe, Paola; Poulle, Marie-Lazarine; Rinaldi, Laura; Samorek-Pieróg, Małgorzata; Santolamazza, Federica; Santoro, Azzurra; Santucciu, Cinzia; Saarma, Urmas; Schnyder, Manuela; Villena, Isabelle; Wassermann, Marion; Casulli, Adriano; Boué, FranckCystic and alveolar echinococcosis are severe zoonotic diseases characterized by long asymptomatic periods lasting months or years. Viable Echinococcus spp. eggs released into the environment through the feces of canids can infect humans through accidental ingestion via hand-to-mouth contact or consumption of contaminated food or water. Both Echinococcus multilocularis and Echinococcus granulosus sensu lato are considered as foodborne parasites. However, when considering possible pathways of human infection, it appears that food and water-borne related variables do not significantly increase the risk of infection. Providing evidence-based data for the presence of DNA and, potentially, eggs in fresh produce is crucial in understanding foodborne transmission of Echinococcus spp. to humans. Two multicenter and multicountry studies were conducted within the One Health EJP framework to estimate the proportion of lettuces and berries contaminated by E. multilocularis, E. granulosus sensu lato, and other taeniid DNAs from a total of 12 European countries, Tunisia and Pakistan. A total of 1117 lettuces, 71 others vegetables, 300 strawberries, 130 blueberries and 50 others berries samples were collected and analysed by washing, sequential sieving and real-time PCRs. E. multilocularis DNA was detected in 1.2 % (7/570) of lettuce samples tested from the seven European endemic countries (Denmark, France, Germany, Latvia, the Netherlands, Poland and Switzerland) and in 2 % (2/100) from Pakistan. E. granulosus sensu lato DNA was identified in 1.3 % of lettuces (9/695) collected in five European endemic countries (France, Italy, Latvia, Poland and Portugal) and in 12 % (9/75) and 4 % (4/100) from Tunisia and Pakistan, respectively. All E. granulosus sensu lato samples were identified as E. granulosus sensu stricto (20/22), except for two identified as E. canadensis (2/22) from Latvia and Pakistan. Regarding berries, E. multilocularis DNA was detected in 5.4 % (n = 11/202) of strawberries, 7.3 % (6/82) of blueberries from the seven European endemic countries and 56 % (14/25) of blueberries from Pakistan. High contamination rates of E. granulosus sensu stricto were found outside of Europe, with 12.0 % (3/25) in blueberries from Pakistan and 81.3 %. (13/16) in strawberries from Tunisia. The total contamination rate of all taeniid species DNA in lettuces (5.3 %; 59/1117), others vegetables (5.6 %; 4/71) and berries (12.1 %; 58/480) suggests that the transfer of taeniid eggs from carnivore feces to food is not uncommon. Although we assume that eggs are the source of the DNA detected in this study, the viability of such eggs is unknown. The detection of Echinococcus species in lettuces and berries suggests a potential risk of foodborne human infection. The relative contribution of this risk remains to be estimated. Further studies on food and environmental contamination are necessary to cover different epidemiological contexts and social habits, leading to a better understanding of human infections by Echinococcus spp. eggs.
- Identification of a mouse-virulent recombinant type I/III Toxoplasma gondii strain in liver cytology of an immunosuppressed cat infected with FeLV-C subgroupPublication . Fonseca, Joana; Almeida, Pedro; Campos, Sónia; Borges, Vítor; Vilares, Anabela; Reis, Tânia; Gargaté, Maria João; Belas, AdrianaToxoplasma gondii infection is common in cats, though clinical disease is uncommon and typically occurs in immunocompromised individuals. Till now, there is no specific genotype that can be associated with a certain clinical outcome. A 5-year-old Siamese cat, diagnosed as Feline Leukemia Virus (FeLV)-positive and classified within the FeLV-C subgroup, presented with a two-month history of progressive lethargy, hyporexia, weight loss, and non-regenerative anemia. The cat, a rescued stray with ongoing outdoor access, had previously responded to doxycycline and prednisolone for presumed Mycoplasma spp. infection, but relapsed and began showing signs of discomfort in head and neck regions, consistent with peripheral neuropathy/ encephalitis. Despite treatment with raltegravir, prednisolone, darbopoetin alfa, cyclosporine and clindamycin (although unknown effectiveness of oral administration), clinical deterioration occurred. The cat developed fever, severe anemia, neutropenia, hyperbilirubinemia, hypoglycaemia and elevated ALT activity. Imaging revealed diffuse hepatic changes and a pulmonary interstitial pattern. Liver FNA identified T. gondii organisms, confirmed by qPCR. Despite the initiation of intravenous clindamycin and trimethoprim-sulfamethoxazole, the cat developed seizures, acute respiratory distress, and septic shock, leading to euthanasia. Genotyping of the hepatic T. gondii isolate via targeted NGS at 13 loci revealed a strain with a recombinant type I/III profile. This mosaicism was previously associated with high virulence in mice and also detected in human patients from the same geographical region. This case highlights the variable presentation of toxoplasmosis in cats and contributes to the scarce knowledge of circulating strains in animals. Characterizing the genetic background of strains could identify sources during zoonotic outbreaks and identify genotypes associated with specific clinical manifestations.
- Undetected circulation of monkeypox virus in Portugal: Evidence for a 50-day gap before first detectionPublication . Cordeiro, Rita; Batista, Fernando da Conceição; Pelerito, Ana; De carvalho, Isabel; Lopo, Sílvia; Neves, Raquel; Rocha, Raquel; Palminha, Paula; Borrego, Maria José; Nuncio, MS; Gomes, João PauloAs mpox continues to spread globally, proactive monitoring and preparedness are crucial to minimize impact and enhance response strategies. Using a mathematical model combining a negative binomial distribution with Richards' logistic curve, we reconstructed the hidden phase of mpox transmission in Portugal, offering insights into the timing and dynamics of the initial outbreak. The analysis of 950 PCR-positive and 986 negative cases suggested that symptom onset occurred between March 24 and April 2, 2022, with March 27 identified as the most probable date. This study delineates the likely period of silent circulation of MPXV in Portugal, providing a clearer understanding of early outbreak dynamics and surveillance performance. Possible imperfections in early diagnostic testing and limited awareness of mpox may have contributed to delayed recognition of the outbreak. By demonstrating how retrospective mathematical modelling can estimate undetected transmission periods, our findings highlight the value of such approaches in epidemic reconstruction and underscore the importance of strengthening early surveillance systems to detect undiagnosed transmission of mpox in non-endemic countries.