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- Measurement error in self-reported risk factors for cardiovascular disease: results from the first Portuguese National Health Examination SurveyPublication . Kislaya, Irina; Nunes, Baltazar; Tolonen, HannaABSTRACT - Accurate data on cardiovascular disease risk factors are essential for the design and evaluation of public health policies. Currently, self-reported data on hypertension and hypercholesterolemia constitute a primary data source for population health monitoring at European and national level. This thesis aimed to evaluate accuracy of self-reported data on hypertension and hypercholesterolemia, to quantify, and to correct measurement error bias using data from the first Portuguese Health Examination Survey (INSEF). Measurements of blood pressure and total cholesterol concentrations were used as gold-standards to estimate measurement error bias, sensitivity and specificity of selfreports, investigate error impact on outcome-exposure associations and illustrate application of multiple imputation for bias correction. Despite all the efforts to limit the error through design and fieldwork procedures, self-reported data underestimated prevalence of hypertension and hypercholesterolemia in Portuguese population. Being unequally distributed among socioeconomic subgroups, measurement errors resulted in underestimation of socioeconomic inequalities in younger and overestimation in older age groups. The study results highlight the importance of measurement error bias analysis when using self-reported data. Results from multiple imputation show the approach feasibility for measurement error bias adjustment in prevalence estimates and outcome-exposure associations when individual-level validation data is available. Health statistics on cardiovascular disease risk factors derived from self-reports should be used with caution. Integration of objective measurements in large-scale health surveys will improve the accuracy of epidemiological information on hypertension and hypercholesterolemia. RESUMO - Informação epidemiológica de qualidade sobre os fatores de risco para doenças cardiovasculares é essencial para formulação e avaliação das políticas de saúde. Atualmente, os dados autoreportados sobre hipertensão e hipercolesterolemia constituem uma fonte primária de informação para monitorização da saúde da população a nível europeu e nacional. O objetivo desta tese é avaliar a qualidade dos dados autoreportados sobre hipertensão e hipercolesterolemia, quantificar e corrigir o viés de medição assocados à informação autoreportada utilizando os dados do primeiro Inquérito Nacional de Saúde com Exame Físico (INSEF). Considerando medições diretas da tensão arterial e do colesterol total como padrão, estimou-se a sensibilidade e a especificidade dos dados autoreportados, avaliou-se o impacto do erro da medição nas estimativas da prevalências e medidas de associação. Adicionalmente, o trabalho desenvolvido ilustrou a aplicação de imputação múltipla para correção de viés de medição. Os dados autoreportados subestimaram a prevalência de hipertensão e hipercolesterolemia na população portuguesa comparativamente às medições diretas. O grau diferencial de viés por estatuto socioeconómico leva a subestimação das desigualdades socioeconómicas nos mais jovens e superestimação nos grupos com a idade mais avançada. Os resultados do estudo realçam a importância da análise de viés associados à medição na utilização dos dados autoreportados. Os resultados da imputação múltipla indicam a viabilidade desta estratégia no ajuste das estimativas da prevalência e medidas de associação quando estão disponíveis a nível individual os dados das medições diretas. As estatísticas de saúde derivadas dos dados autoreportados devem ser usadas com cautela. A integração das medições objetivas nos inquéritos de saúde de base populacional permitirá obter informação epidemiológica de melhor qualidade para monitorização da hipertensão e hipercolesterolemia.
- Impact of infant pneumococcal vaccination on pneumococcal pneumonia hospitalizations in older adultsPublication . Kislaya, Irina; Rodrigues, Ana Paula; Sousa-Uva, Mafalda; Gómez, Verónica; Gonçalves, Paulo; Froes, Filipe; Nunes, BaltazarPneumonia is an important cause of morbidity, mortality and expenditure of health resources. Since the introduction of conjugated pneumococcal vaccines (PCV) in infant immunization programs in 2000s, there is consistent evidence of pneumonia reduction in vaccinated children1. Limited data are available on indirect effect of infant immunization on pneumonia burden in unvaccinated population subgroups. This study aims to assess the indirect effect of the introduction of infant 7-valent (PCV7) and 13-valent (PCV13) pneumococcal conjugated vaccines on the pneumonia burden among adults aged 65 or more years in Portugal, comparing trends in Pneumococcal Pneumonia (PP) hospitalization rates before and after the introduction of the PCV7/PCV13.
- COVID-19 vaccine effectiveness among healthcare workers: a hospital-based cohort studyPublication . Gaio, Vânia; Santos, Ana João; Amaral, Palmira; Faro Viana, João; Antunes, Isabel; Pacheco, Vânia; Paiva, Artur; Pinto Leite, Pedro; Antunes Gonçalves, Lígia; Araújo, Lucília; Silva, Adriana; Matias Dias, Carlos; Kislaya, Irina; Nunes, Baltazar; Machado, AusendaObjectives: Healthcare workers (HCWs) were the first to be prioritised for COVID-19 vaccination. This study aims to estimate the COVID-19 vaccine effectiveness (VE) against SARS-CoV-2 symptomatic infection among HCWs in Portuguese hospitals. Design: Prospective cohort study. Setting and participants: We analysed data from HCWs (all professional categories) from three central hospitals: one in the Lisbon and Tagus Valley region and two in the central region of mainland Portugal, between December 2020 and March 2022. VE against symptomatic SARS-CoV-2 infection was estimated as one minus the confounder adjusted HRs by Cox models considering age group, sex, self-reported chronic disease and occupational exposure to patients diagnosed with COVID-19 as adjustment variables. Results: During the 15 months of follow-up, the 3034 HCWs contributed a total of 3054 person-years at risk, and 581 SARS-CoV-2 events occurred. Most participants were already vaccinated with a booster dose (n=2653, 87%), some are vaccinated with only the primary scheme (n=369, 12.6%) and a few remained unvaccinated (n=12, 0.4%) at the end of the study period. VE against symptomatic infection was 63.6% (95% CI 22.6% to 82.9%) for HCWs vaccinated with two doses and 55.9% (95% CI -1.3% to 80.8%) for HCWs vaccinated with one booster dose. Point estimate VE was higher for individuals with two doses taken between 14 days and 98 days (VE=71.9%; 95% CI 32.3% to 88.3%). Conclusion: This cohort study found a high COVID-19 VE against symptomatic SARS-CoV-2 infection in Portuguese HCWs after vaccination with one booster dose, even after Omicron variant occurrence. The small sample size, the high vaccine coverage, the very low number of unvaccinated individuals and the few events observed during the study period contributed to the low precision of the estimates.
- Health and economic impact of seasonal influenza mass vaccination strategies in European settings: A mathematical modelling and cost-effectiveness analysisPublication . Sandmann, Frank; van Leeuwen, Edwin; Bernard-Stoecklin, Sibylle; Casado, Itziar; Castilla, Jesús; Domegan, Lisa; Gherasim, Alin; Hooiveld, Mariëtte; Kislaya, Irina; Larrauri, Amparo; Levy-Bruhl, Daniel; Machado, Ausenda; Marques, Diogo; Martínez-Baz, Iván; Mazagatos, Clara; McMenamin, Jim; Meijer, Adam; Murray, Josephine; Nunes, Baltazar; O'Donnell, Joan; Reynolds, Arlene; Thorrington, Dominic; Pebody, Richard; Baguelin, MarcIntroduction: Despite seasonal influenza vaccination programmes in most countries targeting individuals aged ≥ 65 (or ≥ 55) years and high risk-groups, significant disease burden remains. We explored the impact and cost-effectiveness of 27 vaccination programmes targeting the elderly and/or children in eight European settings (n = 205.8 million). Methods: We used an age-structured dynamic-transmission model to infer age- and (sub-)type-specific seasonal influenza virus infections calibrated to England, France, Ireland, Navarra, The Netherlands, Portugal, Scotland, and Spain between 2010/11 and 2017/18. The base-case vaccination scenario consisted of non-adjuvanted, non-high dose trivalent vaccines (TV) and no universal paediatric vaccination. We explored i) moving the elderly to "improved" (i.e., adjuvanted or high-dose) trivalent vaccines (iTV) or non-adjuvanted non-high-dose quadrivalent vaccines (QV); ii) adopting mass paediatric vaccination with TV or QV; and iii) combining the elderly and paediatric strategies. We estimated setting-specific costs and quality-adjusted life years (QALYs) gained from the healthcare perspective, and discounted QALYs at 3.0%. Results: In the elderly, the estimated numbers of infection per 100,000 population are reduced by a median of 261.5 (range across settings: 154.4, 475.7) when moving the elderly to iTV and by 150.8 (77.6, 262.3) when moving them to QV. Through indirect protection, adopting mass paediatric programmes with 25% uptake achieves similar reductions in the elderly of 233.6 using TV (range: 58.9, 425.6) or 266.5 using QV (65.7, 477.9), with substantial health gains from averted infections across ages. At €35,000/QALY gained, moving the elderly to iTV plus adopting mass paediatric QV programmes provides the highest mean net benefits and probabilities of being cost-effective in all settings and paediatric coverage levels. Conclusion: Given the direct and indirect protection, and depending on the vaccine prices, model results support a combination of having moved the elderly to an improved vaccine and adopting universal paediatric vaccination programmes across the European settings.
- Impact of influenza vaccination strategy on medically attended influenza in Portugal in five pre-pandemic seasons (2015/16 to 2019/20)Publication . Machado, Ausenda; Kislaya, IrinaBackground: There is limited research on the impact of the yearly influenza vaccination programs in the eligible population. This study aimed to estimate the number of primary care medically attended influenza-confirmed cases (MAICC) among the population aged ≥65 years averted by influenza vaccination programme in Portugal during five seasons in the pre-COVID pandemic period (2015/16 to 2019/20). Methods: We compared the number of observed MAICC to the estimated number that would have occurred in a population without seasonal influenza vaccination (N). To estimate N, we used: i) number of MAICC estimated from national influenza surveillance systems, ii) vaccine coverage (VC) collected in a national telephone survey, iii) influenza vaccine effectiveness (IVE) estimates weighted by the proportion of virus circulation each season in Portugal. We estimated the number of MAICC averted (NAE) by the influenza vaccination programme per 100.000 inhabitants and number needed to vaccinate to prevent one MAICC. We used Monte-Carlo simulations to estimate 95% uncertainty intervals (UI). Results: Comparing with results from 2015/16 to 2017/18 (NAE ranged 24 to 44 per 100.000 inhab) the season 2018/19 showed the highest NAE (62.3 per 100.000 inhab) attributed to the influenza vaccination programme. In 2019/20 season the vaccination strategy averted approximately 11.7 per 100.000 inhab (95%UI: 6.0 to 20.9) events and it was necessary to vaccinate 549 (95%UI: 436 to 742) to prevent one MAICC in primary care. Conclusion: The influenza vaccination strategy had consistent and positive benefit, with more pronounced impact in 2018/19 season. This results were mainly due to a combination of a higher vaccination coverage assumed for 2018/19 (60.8%) and one of the highest vaccine effectiveness (34.8% vs. previous study range 8.5% to 40.6%). To maximize its impact, efforts should be conducted to increase the vaccine coverage. In addition, the surge for more effective vaccines should be maintained.
- Não utilização de instrumentos de avaliação cognitiva em crianças com Paralisia CerebralPublication . Santos, Ana João; Folha, Teresa; Kislaya, Irina; Virella, DanielAntecedentes/Objetivos: A avaliação da cognição na paralisia cerebral (PC) permite adequar apoios à criança e optimizar o seu potencial. Exploram-se factores associados à não utilização de instrumentos de avaliação cognitiva. Métodos: O Programa de Vigilância Nacional da Paralisia Cerebral, desenvolve vigilância ativa da PC em Portugal, na idade alvo de 5 anos, seguindo o protocolo comum da SCPE. Considerou-se a informação registada sobre avaliação cognitiva como “avaliação por teste” e “outra avaliação”. Foram estudados os casos notificados até setembro de 2018, nascidos em 2001-2010, residentes em Portugal. Foram exploradas associações bivariáveis entre a não-“avaliação por teste” e factores sociogeográficos, clínicos e funcionais. Foram estimados odds ratio (OR) num modelo de regressão logística hierárquico. Resultados: Das 1719 crianças notificadas, 1394 tinham informação sobre a avaliação cognitiva; 381 (27,3%) através de teste estandardizado. Distribuição da competência cognitiva: défice grave 46,6%(n=650); défice moderado 14,5%(n=202) e sem défice 38,9%(n=542). As crianças com “avaliação por teste” foram classificadas com défice cognitivo grave (22,8%,n=87), com défice moderado (22,6%,n=86) e sem défice (54,6%,n=208). No modelo final, a possibilidade de não-“avaliação por teste” associou-se à não inteligibilidade da fala (aOR=3,9;[2,9;5,4]), ao défice visual grave (aOR=2,8;[1,4;5,3]) e à PC de tipo disquinético (aOR=2,8;[1,3;6,1]). Conclusões/Recomendações: A avaliação estandardizada da competência cognitiva não é feita em mais de 72% das crianças com PC. As características do tipo clínico, as competências de comunicação e visuais são determinantes para a não avaliação estandardizada da competência cognitiva das crianças com PC. Deve haver equipas com competências técnicas e recursos adequados às necessidades destas crianças.
- Prevalence, awareness, treatment and control of diabetes in Portugal: Results from the first National Health Examination Survey (INSEF 2015)Publication . Barreto, Marta; Kislaya, Irina; Gaio, Vânia; Rodrigues, Ana Paula; Santos, Ana João; Namorado, Sónia; Antunes, Liliana; Gil, Ana Paula; Boavida, José Manuel; Ribeiro, Rogério Tavares; Silva, Ana Clara; Vargas, Patrícia; Prokopenko, Tamara; Nunes, Baltazar; Matias Dias, Carlos; INSEF Research GroupAims: Diabetes Mellitus is a major public health threat worldwide and continues to increase in numbers and significance. Estimates of diabetes prevalence, awareness, treatment and control are essential to effectively monitor its trends, plan and evaluate interventions. Methods: We conducted a nationwide health examination survey in the population residing in Portugal aged between 25 and 74 years old in 2015. It consisted in a cross sectional prevalence study which included the measurement of HbA1c, a physical examination and a general health interview of a probabilistic sample of 4911 individuals (Authorization n°9348/2010 of the National Committee for Data Protection). Results: The overall prevalence of diabetes was 9.9% (95%CI: 8.4; 11.5). It was higher in males than in females (12.1% vs 7.8%). Diabetes was more prevalent among individuals of lower education and without any professional activity. The majority of persons with diabetes was aware of their condition (87.1%) and was taking antidiabetic medication (79.7%). Of these, 63.2% had glycated hemoglobin levels lower than 7.0% (53 mmol/mol), but the majority failed to comply with the LDL and blood pressure recommended clinical targets (71.9% and 59.0%). Similarly, the prevalence of prediabetes was 16%, higher among women than men (17.5% vs 14.4%). Conclusion: The prevalence of diabetes and prediabetes remains higher than the global and European estimates, although there is increasing awareness of this disorder.
- Consumo adicional de sal em Portugal: resultados do Inquérito Nacional de Saúde com Exame Físico 2015Publication . Salvador, Mário Rui; Kislaya, Irina; Namorado, Sónia; Rodrigues, Ana Paula; Santos, Ana João; Santos, Joana; Barreto, Marta; Gaio, Vânia; Nunes, Baltazar; Matias Dias, CarlosIntrodução Nas últimas décadas, estudos epidemiológicos têm demonstrado a associação entre o elevado consumo de sódio e o aumento da pressão arterial e outros eventos cardiovasculares. Apesar da OMS recomendar a ingestão de 5g de sal/dia, o estudo PHYSA realizado em 2012 mostrou que o consumo da população Portuguesa era de 10,7g de sal/dia. Tendo a redução do consumo de sal sido identificada com uma das intervenções mais custo-efetivas na redução da carga de doença crónica, é importante a caracterização dos padrões de consumo na população com vista ao planeamento de estratégias de redução de consumo de sal em diferentes grupos populacionais. Métodos Foi realizado um estudo epidemiológico transversal com base nos dados do Inquérito Nacional de Saúde com Exame Físico (INSEF). O consumo adicional de sal foi avaliado numa amostra probabilística representativa da população portuguesa (n=4911), com a questão “Costuma adicionar sal no prato da sua comida? (Sim/Não)”. Foi estimada a prevalência do consumo de sal e os respetivos intervalos de confiança a 95% para o total de população e estratificada por sexo, grupo etário, região, escolaridade, situação perante o trabalho e diagnóstico de hipertensão arterial. Resultados O consumo adicional de sal foi reportado por 17,7% [IC: 14,2; 21,9] da população. O consumo adicional de sal foi mais frequente entre os homens (20,9% [IC: 16,2; 26,5]), nos residentes na região do Algarve (35,8% [IC: 32,5; 39,3]) e entre os indivíduos empregados (19,6% [IC: 15,4; 24,6]) e variou com a idade de 22% [IC: 17,2; 27,6] no grupo etário mais jovem a 14% [IC: 10,6; 18,3] no grupo etário dos 65-74 anos. Os resultados revelam, ainda, que 13,7% [IC: 9,4; 19,5] da população com diagnóstico de hipertensão arterial refere um consumo adicional de sal. Conclusões Os resultados obtidos permitem concluir que a prevalência de consumo adicional de sal é maior em homens, em grupos etários mais jovens, em indivíduos empregados e na região do Algarve. O consumo adicional de sal nos indivíduos com diagnóstico de hipertensão arterial mostra um comportamento contrário às orientações preconizadas para controlo dos valores de pressão arterial nesta população. Os serviços de saúde pública deverão, neste sentido, centrar as estratégias de redução de consumo de sal nestes grupos populacionais, particularmente em indivíduos com diagnóstico de hipertensão arterial e que estão, por isso, sob maior risco de eventos cardiocerebrovasculares.
- Vaccine effectiveness against COVID-19 hospitalisation in adults (≥ 20 years) during Alpha- and Delta-dominant circulation: I-MOVE-COVID-19 and VEBIS SARI VE networks, Europe, 2021Publication . Rose, Angela M.C.; Nicolay, Nathalie; Sandonis Martín, Virginia; Mazagatos, Clara; Petrović, Goranka; Niessen, F Annabel; Machado, Ausenda; Launay, Odile; Denayer, Sarah; Seyler, Lucie; Baruch, Joaquin; Burgui, Cristina; Loghin, Isabela I.; Domegan, Lisa; Vaikutytė, Roberta; Husa, Petr; Panagiotakopoulos, George; Aouali, Nassera; Dürrwald, Ralf; Howard, Jennifer; Pozo, Francisco; Sastre-Palou, Bartolomé; Nonković, Diana; Knol, Mirjam J.; Kislaya, Irina; Luong Nguyen, Liem binh; Bossuyt, Nathalie; Demuyser, Thomas; Džiugytė, Aušra; Martínez-Baz, Iván; Popescu, Corneliu; Duffy, Róisín; Kuliešė, Monika; Součková, Lenka; Michelaki, Stella; Simon, Marc; Reiche, Janine; Otero-Barrós, María Teresa; Lovrić Makarić, Zvjezdana; Bruijning-Verhagen, Patricia C.J.L.; Gómez, Verónica; Lesieur, Zineb; Barbezange, Cyril; Van Nedervelde, Els; Borg, Maria-Louise; Castilla, Jesús; Lazar, Mihaela; O’Donnell, Joan; Jonikaitė, Indrė; Demlová, Regina; Amerali, Marina; Wirtz, Gil; Tolksdorf, Kristin; Valenciano, Marta; Bacci, Sabrina; Kissling, Esther; I-MOVE-COVID-19 Hospital Study Team; VEBIS Hospital Study TeamIntroduction: Two large multicentre European hospital networks have estimated vaccine effectiveness (VE) against COVID-19 since 2021. Aim: We aimed to measure VE against PCR-confirmed SARS-CoV-2 in hospitalised severe acute respiratory illness (SARI) patients ≥ 20 years, combining data from these networks during Alpha (March–June)- and Delta (June–December)-dominant periods, 2021. Methods: Forty-six participating hospitals across 14 countries follow a similar generic protocol using the test-negative case–control design. We defined complete primary series vaccination (PSV) as two doses of a two-dose or one of a single-dose vaccine ≥ 14 days before onset. Results: We included 1,087 cases (538 controls) and 1,669 cases (1,442 controls) in the Alpha- and Delta-dominant periods, respectively. During the Alpha period, VE against hospitalisation with SARS-CoV2 for complete Comirnaty PSV was 85% (95% CI: 69–92) overall and 75% (95% CI: 42–90) in those aged ≥ 80 years. During the Delta period, among SARI patients ≥ 20 years with symptom onset ≥ 150 days from last PSV dose, VE for complete Comirnaty PSV was 54% (95% CI: 18–74). Among those receiving Comirnaty PSV and mRNA booster (any product) ≥ 150 days after last PSV dose, VE was 91% (95% CI: 57–98). In time-since-vaccination analysis, complete all-product PSV VE was > 90% in those with their last dose < 90 days before onset; ≥ 70% in those 90–179 days before onset. Conclusions: Our results from this EU multi-country hospital setting showed that VE for complete PSV alone was higher in the Alpha- than the Delta-dominant period, and addition of a first booster dose during the latter period increased VE to over 90%.
- Exploring victimization patterns with latent class analysis: new Approaches to elder abusePublication . Santos, Ana João; Nunes, Baltazar; Kislaya, Irina; Gil, Ana Paula; Ribeiro, OscarObjectives: Recognized as an important public health issue, elder abuse has been associated with adverse health and social outcomes. However, findings are often complex and contradictory, which can be attributed to elder abuse being a multidimensional construct that encompasses a set of different abusive behaviours, victims, perpetrators and settings. The array of possible elder abuse configurations is difficult to capture. This study sought to identify victimization patterns that represent distinct elder abuse configurations based on specific abusive behaviours and on the relationship with the perpetrator; it also sought to determine the association between these latent classes with victims’ characteristics. Methods: Data comes from two elder abuse surveys: a representative sample of community-dwelling adults and a convenience sample of older adults reporting elder abuse to four state and NGOs institutions. Latent Class Analysis (LCA) was used to categorize victimization in the population-based (N=245) and in the victims’ sample (N=510) using 7 items measuring physical, psychological and financial abuse, and appointed perpetrators. Chi-square tests were used to compare victims’ characteristics between the different obtained classes. Results: The LCA procedure identified six different latent classes of victimization experiences in each of the samples, which were statistically and plausibly distinct. In the population-based survey: verbal abuse by others (29%); psychological abuse from children/grandchildren (18%); overlooked by others (18%); stolen by others (15%); verbal IPV (14%) and physical and psychological IPV (6%). In the victims’ survey: physical abuse by children/grandchildren (29%); physical IPV (26%); psychological abuse by children/grandchildren (18%); polyvictimization by others (16%); physical abuse by others (6%) and physical and psychological IPV (4%). In the victims survey the six groups significantly differ in age, gender, civil status, cohabitation, perceived social support and functional status. Conclusion: The results support the possibility of the multidimensionality of elder abuse not being accounted by the “classical” abuse typologies. Elder abuse victims seeking help may represent a distinct group from that included in population-based prevalence studies. The appointed perpetrators may be the most meaningful and relevant aspect in distinguishing victimization experiences. Further research is needed to develop tailored interventions to specific elder abuse cases and enhance successful outcomes.