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Shastry RP, Bajire SK, Banerjee S, Shastry KP, Hameed A. Association Between Biofilm Formation and Extended-Spectrum Beta-Lactamase Production in Klebsiella pneumoniae Isolated from Fresh Fruits and Vegetables. Curr Microbiol 2024; 81:206. [PMID: 38831051 DOI: 10.1007/s00284-024-03723-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/29/2024] [Indexed: 06/05/2024]
Abstract
The presence of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae in fresh fruits and vegetables is a growing public health concern. The primary objective of this study was to investigate the relationship between biofilm formation and extended-spectrum β-lactamase (ESBL) production in K. pneumoniae strains obtained from fresh fruits and vegetables. Out of 120 samples analysed, 94 samples (78%) were found to be positive for K. pneumoniae. Among the K. pneumoniae strains isolated, 74.5% were from vegetables, whereas the remaining (25.5%) were from fresh fruits. K. pneumoniae isolates were resistant to at least three different classes of antibiotics, with ceftazidime (90%) and cefotaxime (70%) showing the highest resistance rates. While the high occurrence of ESBL-producing and biofilm-forming K. pneumoniae strains were detected in vegetables (73.5% and 73.7%, respectively), considerable amounts of the same were also found in fresh fruits (26.5% and 26.3%, respectively). The results further showed a statistically significant (P < 0.001) association between biofilm formation and ESBL production in K. pneumoniae strains isolated from fresh fruits and vegetables. Furthermore, the majority (81%) of the ESBL-producing strains harbored the blaCTX-M gene, while a smaller proportion of strains carried the blaTEM gene (30%), blaSHV gene (11%) or blaOXA (8%). This study highlights the potential public health threat posed by K. pneumoniae in fresh fruits and vegetables and emphasizes the need for strict surveillance and control measures.
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Affiliation(s)
- Rajesh Padumane Shastry
- Division of Microbiology and Biotechnology, Yenepoya Research Centre, Yenepoya (Deemed to Be University), University Road, Deralakatte, Mangaluru, 575018, India.
| | - Sukesh Kumar Bajire
- Division of Microbiology and Biotechnology, Yenepoya Research Centre, Yenepoya (Deemed to Be University), University Road, Deralakatte, Mangaluru, 575018, India
| | - Shukla Banerjee
- Division of Microbiology and Biotechnology, Yenepoya Research Centre, Yenepoya (Deemed to Be University), University Road, Deralakatte, Mangaluru, 575018, India
| | - Kavyashree Padumane Shastry
- Department of Microbiology, Yenepoya Institute of Arts, Science, Commerce and Management, Yenepoya (Deemed to Be University), Kulur, Mangaluru, 575013, India
| | - Asif Hameed
- Division of Microbiology and Biotechnology, Yenepoya Research Centre, Yenepoya (Deemed to Be University), University Road, Deralakatte, Mangaluru, 575018, India
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Gupta SS, Hamza Kh M, Sones CL, Zhang X, Sivaraman GK. The CRISPR/Cas system as an antimicrobial resistance strategy in aquatic ecosystems. Funct Integr Genomics 2024; 24:110. [PMID: 38806846 DOI: 10.1007/s10142-024-01362-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/22/2024] [Accepted: 04/27/2024] [Indexed: 05/30/2024]
Abstract
With the growing population, demand for food has dramatically increased, and fisheries, including aquaculture, are expected to play an essential role in sustaining demand with adequate quantities of protein and essential vitamin supplements, employment generation, and GDP growth. Unfortunately, the incidence of emerging/re-emerging AMR pathogens annually occurs because of anthropogenic activities and the frequent use of antibiotics in aquaculture. These AMR pathogens include the WHO's top 6 prioritized ESKAPE pathogens (nosocomial pathogens: Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.), extended-spectrum beta lactases (ESBLs) and carbapenemase-producing E. coli, which pose major challenges to the biomagnification of both nonnative and native antibiotic-resistant bacteria in capture and cultured fishes. Although implementing the rational use of antibiotics represents a promising mitigation measure, this approach is practically impossible due to the lack of awareness among farmers about the interplay between antimicrobial use and the emergence of antimicrobial resistance (AMR). Nevertheless, to eradicate these 'superbugs,' CRISPR/Cas (clustered regularly interspersed short palindromic repeats/CRISPR associate protein) has turned out to be a novel approach owing to its ability to perform precise site-directed targeting/knockdown/reversal of specific antimicrobial resistance genes in vitro and to distinguish AMR-resistant bacteria from a plethora of commensal aquatic bacteria. Along with highlighting the importance of virulent multidrug resistance genes in bacteria, this article aims to provide a holistic picture of CRISPR/Cas9-mediated genome editing for combating antimicrobial-resistant bacteria isolated from various aquaculture and marine systems, as well as insights into different types of CRISPR/Cas systems, delivery methods, and challenges associated with developing CRISPR/Cas9 antimicrobial agents.
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Affiliation(s)
- Sobin Sonu Gupta
- Founder & CEO at Times of Biotech, Navelim Bicholim, Goa-403505, India
- Microbiology, Fermentation & Biotechnology Division, ICAR- Central Institute of Fisheries Technology, Cochin-29, Kerala, India
| | - Muneeb Hamza Kh
- Microbiology, Fermentation & Biotechnology Division, ICAR- Central Institute of Fisheries Technology, Cochin-29, Kerala, India
| | - Collin L Sones
- Founder and CTO of Highfield Diagnostics, Zepler Institute of Photonics and Nanoelectronics, University of Southampton, SO17 1BJ, Southampton, UK
| | - Xunli Zhang
- School of Engineering & Institute for Life Sciences, University of Southampton, SO17 1BJ, Southampton, UK
| | - Gopalan Krishnan Sivaraman
- Microbiology, Fermentation & Biotechnology Division, ICAR- Central Institute of Fisheries Technology, Cochin-29, Kerala, India.
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Zhao L, Lv Z, Lin L, Li X, Xu J, Huang S, Chen Y, Fu Y, Peng C, Cao T, Ke Y, Xia X. Impact of COVID-19 pandemic on profiles of antibiotic-resistant genes and bacteria in hospital wastewater. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2023; 334:122133. [PMID: 37399936 DOI: 10.1016/j.envpol.2023.122133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 06/21/2023] [Accepted: 07/01/2023] [Indexed: 07/05/2023]
Abstract
The COVID-19 pandemic has severely affected healthcare worldwide and has led to the excessive use of disinfectants and antimicrobial agents. However, the impact of excessive disinfection measures and specific medication prescriptions on the development and dissemination of bacterial drug resistance during the pandemic remains unclear. This study investigated the influence of the pandemic on the composition of antibiotics, antibiotic resistance genes (ARGs), and pathogenic communities in hospital wastewater using ultra-performance liquid chromatography-tandem mass spectrometry and metagenome sequencing. The overall level of antibiotics decreased after the COVID-19 outbreak, whereas the abundance of various ARGs increased in hospital wastewater. After COVID-19 outbreak, blaOXA, sul2, tetX, and qnrS had higher concentrations in winter than in summer. Seasonal factors and the COVID-19 pandemic have affected the microbial structure in wastewater, especially of Klebsiella, Escherichia, Aeromonas, and Acinetobacter. Further analysis revealed the co-existence of qnrS, blaNDM, and blaKPC during the pandemic. Various ARGs significantly correlated with mobile genetic elements, implying their potential mobility. A network analysis revealed that many pathogenic bacteria (Klebsiella, Escherichia, and Vibrio) were correlated with ARGs, indicating the existence of multi-drug resistant pathogens. Although the calculated resistome risk score did not change significantly, our results suggest that the COVID-19 pandemic shifted the composition of residual antibiotics and ARGs in hospital wastewater and contributed to the dissemination of bacterial drug resistance.
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Affiliation(s)
- Liang Zhao
- National Key Laboratory of Veterinary Public Health Security, College of Veterinary Medicine, China Agricultural University, Beijing, 100193, China
| | - Ziquan Lv
- Shenzhen Center for Disease Control and Prevention, Shenzhen, 518055, China
| | - Liangqiang Lin
- Shenzhen Center for Disease Control and Prevention, Shenzhen, 518055, China
| | - Xiaowei Li
- National Key Laboratory of Veterinary Public Health Security, College of Veterinary Medicine, China Agricultural University, Beijing, 100193, China
| | - Jian Xu
- National Key Laboratory of Veterinary Public Health Security, College of Veterinary Medicine, China Agricultural University, Beijing, 100193, China
| | - Suli Huang
- Shenzhen Center for Disease Control and Prevention, Shenzhen, 518055, China
| | - Yuhua Chen
- Shenzhen Center for Disease Control and Prevention, Shenzhen, 518055, China
| | - Yulin Fu
- Shenzhen Center for Disease Control and Prevention, Shenzhen, 518055, China
| | - Changfeng Peng
- Shenzhen Center for Disease Control and Prevention, Shenzhen, 518055, China
| | - Tingting Cao
- Shenzhen Center for Disease Control and Prevention, Shenzhen, 518055, China
| | - Yuebin Ke
- Shenzhen Center for Disease Control and Prevention, Shenzhen, 518055, China
| | - Xi Xia
- National Key Laboratory of Veterinary Public Health Security, College of Veterinary Medicine, China Agricultural University, Beijing, 100193, China.
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Richter L, Du Plessis EM, Duvenage S, Korsten L. Prevalence of extended-spectrum β-lactamase producing Enterobacterales in Africa's water-plant-food interface: A meta-analysis (2010–2022). FRONTIERS IN SUSTAINABLE FOOD SYSTEMS 2023. [DOI: 10.3389/fsufs.2023.1106082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
BackgroundMultidrug-resistant extended-spectrum β-lactamase (ESBL)-producing Enterobacterales is regarded as a critical health issue, yet, surveillance in the water-plant-food interface remains low, especially in Africa.ObjectivesThe objective of the study was to elucidate the distribution and prevalence of antimicrobial resistance in clinically significant members of the Enterobacterales order isolated from the water-plant-food interface in Africa.MethodsA literature search was conducted using six online databases according to the PRISMA guidelines. All available published studies involving phenotypic and genotypic characterization of ESBL-producing Enterobacterales from water, fresh produce or soil in Africa were considered eligible. Identification and characterization methods used as well as a network analysis according to the isolation source and publication year were summarized. Analysis of Escherichia coli, Salmonella spp. and Klebsiella pneumoniae included the calculation of the multiple antibiotic resistance (MAR) index according to isolation sources and statistical analysis was performed using RStudio.ResultsOverall, 51 studies were included for further investigation. Twelve African countries were represented, with environmental AMR surveillance studies predominantly conducted in South Africa. In 76.47% of the studies, occurrence of antimicrobial resistant bacteria was investigated in irrigation water samples, while 50.98% of the studies included fresh produce samples. Analysis of bacterial phenotypic antimicrobial resistance profiles were reported in 94.12% of the studies, with the disk diffusion method predominantly used. When investigating the MAR indexes of the characterized Escherichia coli, Klebsiella pneumoniae and Salmonella spp., from different sources (water, fresh produce or soil), no significant differences were seen across the countries. The only genetic determinant identified using PCR detection in all the studies was the blaCTX − M resistance gene. Only four studies used whole genome sequence analysis for molecular isolate characterization.DiscussionGlobally, AMR surveillance programmes recognize ESBL- and carbapenemase-producing Enterobacterales as vectors of great importance in AMR gene dissemination. However, in low- and middle-income countries, such as those in Africa, challenges to implementing effective and sustainable AMR surveillance programmes remain. This review emphasizes the need for improved surveillance, standardized methods and documentation of resistance gene dissemination across the farm-to-fork continuum in Africa.
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Zhang Z, Wang Y, Chen B, Lei C, Yu Y, Xu N, Zhang Q, Wang T, Gao W, Lu T, Gillings M, Qian H. Xenobiotic pollution affects transcription of antibiotic resistance and virulence factors in aquatic microcosms. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2022; 306:119396. [PMID: 35525510 DOI: 10.1016/j.envpol.2022.119396] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/08/2022] [Accepted: 04/30/2022] [Indexed: 06/14/2023]
Abstract
Antibiotic resistance genes (ARGs) and virulence factors (VFs) are critical threats to human health. Their abundance in aquatic ecosystems is maintained and enhanced via selection driven by environmental xenobiotics. However, their activity and expression in these environments under xenobiotic stress remains unknown. Here ARG and VF expression profiles were examined in aquatic microcosms under ciprofloxacin, glyphosate and sertraline hydrochloride treatment. Ciprofloxacin increased total expression of ARGs, particularly multidrug resistance genes. Total expression of ARGs and VFs decreased significantly under glyphosate and sertraline treatments. However, in opportunistic human pathogens, these agents increased expression of both ARGs and VFs. Xenobiotic pollutants, such as the compounds we tested here, have the potential to disrupt microbial ecology, promote resistance, and increase risk to human health. This study systematically evaluated the effects of environmental xenobiotics on transcription of ARGs and VFs, both of which have direct relevance to human health. Transcription of such genes has been overlooked in previous studies.
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Affiliation(s)
- Zhenyan Zhang
- College of Environment, Zhejiang University of Technology, Hangzhou, 310032, PR China
| | - Yan Wang
- College of Environment, Zhejiang University of Technology, Hangzhou, 310032, PR China
| | - Bingfeng Chen
- College of Environment, Zhejiang University of Technology, Hangzhou, 310032, PR China
| | - Chaotang Lei
- College of Environment, Zhejiang University of Technology, Hangzhou, 310032, PR China
| | - Yitian Yu
- College of Environment, Zhejiang University of Technology, Hangzhou, 310032, PR China
| | - Nuohan Xu
- College of Environment, Zhejiang University of Technology, Hangzhou, 310032, PR China
| | - Qi Zhang
- College of Environment, Zhejiang University of Technology, Hangzhou, 310032, PR China
| | - Tingzhang Wang
- Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, 310012, PR China
| | - Wenwen Gao
- Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, 310012, PR China
| | - Tao Lu
- College of Environment, Zhejiang University of Technology, Hangzhou, 310032, PR China
| | - Michael Gillings
- ARC Centre of Excellence in Synthetic Biology, Faculty of Science and Engineering, Macquarie University, NSW, 2109, Australia
| | - Haifeng Qian
- College of Environment, Zhejiang University of Technology, Hangzhou, 310032, PR China.
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One Health Perspective of Salmonella Serovars in South Africa Using Pooled Prevalence: Systematic Review and Meta-Analysis. Int J Microbiol 2022; 2022:8952669. [PMID: 35498396 PMCID: PMC9046003 DOI: 10.1155/2022/8952669] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/12/2022] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
Salmonella is a bacterium that is commonly associated with food-borne infections and is regarded as one of the most important pathogens in public health. Salmonella serovars, particularly Typhimurium and Enteritidis, which are widely distributed globally, mainly result in outbreaks commonly linked to the consumption of animal products. This study is a systematic review and meta-analysis of studies reporting the prevalence of Salmonella serovars from one health perspective that included human, environmental, and animal samples in South Africa. PubMed, ScienceDirect, African Journals Online, and Scopus databases were used to conduct extensive searches of articles which were ultimately included or excluded following the Systematic Reviews and Meta-Analysis (PRISMA) guidelines. According to the data obtained in this review, the overall pooled prevalence estimates (PPE) of Salmonella serovars detection were 79.6%, 61.6%, 56.5%, and 43.2% for human, environment, animal, and environment/animal samples in South Africa, respectively. The majority of the studies (50%) used the polymerase chain reaction (PCR) technique for the detection of Salmonella serovars, followed by culture methods (26.7%), while 20% used serotyping. The PPE for nontyphoidal Salmonellae (NTS) was 65.6% and 34.4% for Salmonella Typhimurium and Salmonella Enteritidis, respectively. Our data further shows that 3 serovars, namely, Salmonella Typhimurium, Salmonella Enteriditis, and Salmonella Hadar, have been isolated from animals, humans, and the environment in South Africa. Our results highlight the ongoing spread of Salmonella spp. especially on animals which might end up infecting humans via direct contact with infected animals or eating infected animal products. This calls for deliberate “One Health” epidemiological studies in order to document information on the transmission between humans, animals, and the environment. This will ultimately result in the formulation of a consolidated salmonellosis control policy by the environmental, human, and veterinary health sectors.
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Molecular Detection of Integrons, Colistin and β-lactamase Resistant Genes in Salmonella enterica Serovars Enteritidis and Typhimurium Isolated from Chickens and Rats Inhabiting Poultry Farms. Microorganisms 2022; 10:microorganisms10020313. [PMID: 35208768 PMCID: PMC8876313 DOI: 10.3390/microorganisms10020313] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 12/24/2022] Open
Abstract
The rapid growth of multidrug-resistant Salmonella is a global public health concern. The aim of this study was to detect integrons, colistin and β-lactamase resistance genes in Salmonella enteritidis and typhimurium. A total of 63 isolates of S. enteritidis (n = 18) and S. typhimurium (n = 45) from fecal samples of layers and rats at chicken farms were screened for antibiotic resistant genes. Conventional PCR was performed for the detection of integrons (classes 1, 2, and 3), colistin (mcr-1-5) and β-lactamase (blaCTX-M, blaCTX-M-1, blaCTX-M-2, blaCTX-M-9, blaCTX-M-15, blaTEM, blaSHV, and blaOXA) resistant genes. Of these isolates, 77% and 27% of S. typhimurium and S. enteritidis harboured the mcr-4 encoded gene for colistin, respectively. The prevalence of class 1 integrons for S. typhimurium and S. enteritidis was 100% for each serovar, while for class 2 integrons of S. typhimurium and S. enteritidis it was 49% and 33% respectively, while class 3 integron genes was not detected. Our study also detected high levels of β-lactamase encoding genes (bla gene), namely blaCTX-M, blaCTX-M-1, blaCTX-M-9 and blaTEM from both S. typhimurium and S. enteritidis. This, to our knowledge, is the first report of mcr-4 resistance gene detection in Salmonella serovars in South Africa. This study also highlights the importance of controlling rats at poultry farms in order to reduce the risk of transmission of antibiotic resistance to chickens and eventually to humans.
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Culture dependent and independent detection of multiple extended beta-lactamase producing and biofilm forming Salmonella species from leafy vegetables. BIOCATALYSIS AND AGRICULTURAL BIOTECHNOLOGY 2021. [DOI: 10.1016/j.bcab.2021.102202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Prevalence of extended-spectrum β-lactamase (ESBL)-producing Salmonella enterica from retail fishes in Egypt: A major threat to public health. Int J Food Microbiol 2021; 351:109268. [PMID: 34098467 DOI: 10.1016/j.ijfoodmicro.2021.109268] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/13/2021] [Accepted: 05/24/2021] [Indexed: 01/22/2023]
Abstract
The increase in multidrug-resistant Salmonella enterica and its spread from food to humans are considered a serious public health concern worldwide. Little is currently known about the prevalence of extended-spectrum β-lactamase (ESBL)-producing S. enterica in fish in Africa. Therefore, this study aimed to investigate the existence of ESBL-producing S. enterica in retail fish in Egypt. In total, 200 fish samples were collected randomly from various retail fish markets in Egypt. S. enterica were detected in 19 (9.5%; 95% CI: 5.8-14.4) of the fish samples analyzed. Of the 19 non-repetitive S. enterica isolates, 18 were serologically categorized into eight S. enterica serovars and a non-typable serovar. All 19 S. enterica isolates (100%) showed multidrug-resistant phenotypes to at least three classes of antimicrobials, and 11 (57.9%) exhibited an ESBL-resistant phenotype and harbored at least one ESBL-encoding gene. The ESBL-producing S. enterica serovars were as follows: Kentucky (3 isolates; 15.8%), Enteritidis (2 isolates; 10.5%), Typhimurium (2 isolates; 10.5%), and 1 isolate (5.3%) each of Infantis, Virchow, Paratyphi B, and Senftenberg. The identified β-lactamase-encoding genes included ESBL-encoding genes blaCTX-M-3, blaCTX-M-14, blaCTX-M-15, blaSHV-1, blaSHV-2 and blaSHV-12; the AmpC β-lactamase-encoding gene blaCMY-2; and the narrow-spectrum β-lactamase-encoding genes blaTEM-1 and blaOXA-1. All S. enterica isolates were negative for carbapenemase-encoding genes. Molecular analysis of plasmid transferability and replicon typing revealed that most plasmids (with β-lactamase-encoding genes) were transferrable, and the most common incompatibility groups were IncI1, IncA/C, IncHI1, and IncN. To the best of our knowledge, this is the first report for molecular characterization of ESBL-producing S. enterica in fish in Egypt. The occurrence of ESBL-producing S. enterica in retail fish constitutes a potential public health threat with the possibility of transmission of these strains with resistance genes to humans. Such transmission would exacerbate the resistance to an important class of antibiotics commonly used in hospitals to treat typhoid and non-typhoidal Salmonella infections.
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Viegas C, Viegas S. Special Issue "Antimicrobial Resistance: From the Environment to Human Health". Microorganisms 2021; 9:microorganisms9040686. [PMID: 33810383 PMCID: PMC8065737 DOI: 10.3390/microorganisms9040686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Carla Viegas
- H&TRC-Health & Technology Research Center, ESTeSL-Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal;
- NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, 1990-096 Lisbon, Portugal
- Comprehensive Health Research Center (CHRC), 1169-056 Lisbon, Portugal
- Correspondence:
| | - Susana Viegas
- H&TRC-Health & Technology Research Center, ESTeSL-Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal;
- NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, 1990-096 Lisbon, Portugal
- Comprehensive Health Research Center (CHRC), 1169-056 Lisbon, Portugal
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