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Borges V, Duque MP, Martins JV, Vasconcelos P, Ferreira R, Sobral D, Pelerito A, de Carvalho IL, Núncio MS, Borrego MJ, Roemer C, Neher RA, O'Driscoll M, Rocha R, Lopo S, Neves R, Palminha P, Coelho L, Nunes A, Isidro J, Pinto M, Santos JD, Mixão V, Santos D, Duarte S, Vieira L, Martins F, Machado J, Veríssimo VC, Grau B, Peralta-Santos A, Neves J, Caldeira M, Pestana M, Fernandes C, Caria J, Pinto R, Póvoas D, Maltez F, Sá AI, Salvador MB, Teófilo E, Rocha M, Moneti V, Duque LM, E Silva FF, Baptista T, Vasconcelos J, Casanova S, Mansinho K, Alves JV, Alves J, Silva A, Alpalhão M, Brazão C, Sousa D, Filipe P, Pacheco P, Peruzzu F, de Jesus RP, Ferreira L, Mendez J, Jordão S, Duarte F, Gonçalves MJ, Pena E, Silva CN, Guimarães AR, Tavares M, Freitas G, Cordeiro R, Gomes JP. Viral genetic clustering and transmission dynamics of the 2022 mpox outbreak in Portugal. Nat Med 2023; 29:2509-2517. [PMID: 37696933 PMCID: PMC10579057 DOI: 10.1038/s41591-023-02542-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023]
Abstract
Pathogen genome sequencing during epidemics enhances our ability to identify and understand suspected clusters and investigate their relationships. Here, we combine genomic and epidemiological data of the 2022 mpox outbreak to better understand early viral spread, diversification and transmission dynamics. By sequencing 52% of the confirmed cases in Portugal, we identified the mpox virus sublineages with the highest impact on case numbers and fitted them into a global context, finding evidence that several international sublineages probably emerged or spread early in Portugal. We estimated a 62% infection reporting rate and that 1.3% of the population of men who have sex with men in Portugal were infected. We infer the critical role played by sexual networks and superspreader gatherings, such as sauna attendance, in the dissemination of mpox virus. Overall, our findings highlight genomic epidemiology as a tool for the real-time monitoring and control of mpox epidemics, and can guide future vaccine policy in a highly susceptible population.
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Affiliation(s)
- Vítor Borges
- Genomics and Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Mariana Perez Duque
- Epidemiology and Statistics Division, Directorate-General of Health, Lisbon, Portugal
- Pathogen Dynamics Group, Department of Genetics, University of Cambridge, Cambridge, United Kingdom
| | - João Vieira Martins
- Epidemiology and Statistics Division, Directorate-General of Health, Lisbon, Portugal
| | - Paula Vasconcelos
- Public Health Emergency Centre, Directorate-General of Health, Lisbon, Portugal
| | - Rita Ferreira
- Genomics and Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Daniel Sobral
- Genomics and Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Ana Pelerito
- Emergency Response and Biopreparedness Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Isabel Lopes de Carvalho
- Emergency Response and Biopreparedness Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Maria Sofia Núncio
- Emergency Response and Biopreparedness Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Maria José Borrego
- National Reference Laboratory for Sexually Transmitted Infections, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Cornelius Roemer
- Biozentrum, University of Basel, Basel, Switzerland
- Swiss Institute of Bioinformatics, Basel, Switzerland
| | - Richard A Neher
- Biozentrum, University of Basel, Basel, Switzerland
- Swiss Institute of Bioinformatics, Basel, Switzerland
| | - Megan O'Driscoll
- Pathogen Dynamics Group, Department of Genetics, University of Cambridge, Cambridge, United Kingdom
| | - Raquel Rocha
- National Reference Laboratory for Sexually Transmitted Infections, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Sílvia Lopo
- National Reference Laboratory for Sexually Transmitted Infections, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Raquel Neves
- National Reference Laboratory for Sexually Transmitted Infections, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Paula Palminha
- National Reference Laboratory for Sexually Transmitted Infections, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Luís Coelho
- Genomics and Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Alexandra Nunes
- Genomics and Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
- Veterinary and Animal Research Centre (CECAV), Faculty of Veterinary Medicine, Lusófona University, Lisbon, Portugal
| | - Joana Isidro
- Genomics and Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Miguel Pinto
- Genomics and Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - João Dourado Santos
- Genomics and Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Verónica Mixão
- Genomics and Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Daniela Santos
- Technology and Innovation Unit, Department of Human Genetics, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Silvia Duarte
- Technology and Innovation Unit, Department of Human Genetics, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Luís Vieira
- Technology and Innovation Unit, Department of Human Genetics, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Fátima Martins
- Technical Board, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Jorge Machado
- Department Coordination, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - Vítor Cabral Veríssimo
- Epidemiology and Statistics Division, Directorate-General of Health, Lisbon, Portugal
- Public Health Unit, ACES Cascais, ARSLVT, Cascais, Portugal
| | - Berta Grau
- Epidemiology and Statistics Division, Directorate-General of Health, Lisbon, Portugal
- Public Health Emergency Centre, Directorate-General of Health, Lisbon, Portugal
- ECDC Fellowship Programme, Field Epidemiology path (EPIET), European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
- Directorate of Information and Analysis, Directorate-General of Health, Lisbon, Portugal
| | - André Peralta-Santos
- Directorate of Information and Analysis, Directorate-General of Health, Lisbon, Portugal
- Comprehensive Health Research Centre (CHRC), Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - José Neves
- Serviço de Dermatovenereologia, Consulta de DST, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Margarida Caldeira
- Serviço de Dermatovenereologia, Consulta de DST, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Mafalda Pestana
- Serviço de Dermatovenereologia, Consulta de DST, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Cândida Fernandes
- Serviço de Dermatovenereologia, Consulta de DST, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - João Caria
- Serviço de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Raquel Pinto
- Serviço de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Diana Póvoas
- Serviço de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Fernando Maltez
- Serviço de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Ana Isabel Sá
- Unidade de Doenças Sexualmente Transmissíveis da Lapa, Lisbon, Portugal
| | | | - Eugénio Teófilo
- GAT - Grupo de Ativistas em Tratamentos, Av. Paris, Lisbon, Portugal
| | - Miguel Rocha
- GAT - Grupo de Ativistas em Tratamentos, Av. Paris, Lisbon, Portugal
| | - Virginia Moneti
- GAT - Grupo de Ativistas em Tratamentos, Av. Paris, Lisbon, Portugal
| | - Luis Miguel Duque
- GAT - Grupo de Ativistas em Tratamentos, Av. Paris, Lisbon, Portugal
| | | | - Teresa Baptista
- GAT - Grupo de Ativistas em Tratamentos, Intendente, Lisbon, Portugal
| | - Joana Vasconcelos
- Serviço de Doenças Infeciosas e Medicina Tropical, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Sara Casanova
- Serviço de Doenças Infeciosas e Medicina Tropical, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Kamal Mansinho
- Serviço de Doenças Infeciosas e Medicina Tropical, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - João Vaz Alves
- Serviço de Doenças Infeciosas e Medicina Tropical, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - João Alves
- Serviço de Dermatovenereologia, Hospital Garcia de Orta, Almada, Portugal
| | - António Silva
- Serviço de Dermatovenereologia, Hospital Garcia de Orta, Almada, Portugal
| | - Miguel Alpalhão
- Dermatology Department, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Dermatology Research Unit (PFilipe Lab), Instituto de Medicina Molecular João Lobo Antunes, University of Lisbon, Lisbon, Portugal
- Dermatology University Clinic, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Cláudia Brazão
- Dermatology Department, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Diogo Sousa
- Dermatology Department, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Paulo Filipe
- Dermatology Department, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Dermatology Research Unit (PFilipe Lab), Instituto de Medicina Molecular João Lobo Antunes, University of Lisbon, Lisbon, Portugal
- Dermatology University Clinic, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Patrícia Pacheco
- Serviço de Infeciologia, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Francesca Peruzzu
- Serviço de Infeciologia, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | | | - Luís Ferreira
- Serviço Infeciologia do CHUP, Largo Professor Abel Salazar, Porto, Portugal
| | - Josefina Mendez
- Serviço Infeciologia do CHUP, Largo Professor Abel Salazar, Porto, Portugal
| | - Sofia Jordão
- Serviço de Doenças Infeciosas, Hospital Pedro Hispano - ULS Matosinhos, Matosinhos, Portugal
| | - Frederico Duarte
- Serviço de Doenças Infeciosas, Hospital Pedro Hispano - ULS Matosinhos, Matosinhos, Portugal
| | - Maria João Gonçalves
- Serviço de Doenças Infeciosas, Hospital Pedro Hispano - ULS Matosinhos, Matosinhos, Portugal
| | - Eduarda Pena
- Serviço de Doenças Infeciosas, Hospital Pedro Hispano - ULS Matosinhos, Matosinhos, Portugal
| | - Claúdio Nunes Silva
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário de São João, Porto, Portugal
| | | | - Margarida Tavares
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Graça Freitas
- National Health Authority, Directorate-General of Health, Lisbon, Portugal
| | - Rita Cordeiro
- Emergency Response and Biopreparedness Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal
| | - João Paulo Gomes
- Genomics and Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge (INSA), Lisbon, Portugal.
- Veterinary and Animal Research Centre (CECAV), Faculty of Veterinary Medicine, Lusófona University, Lisbon, Portugal.
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Caria J, Vara-Luiz F, Maia I, Joosten A, Val-Flores L, Pinheiro H, Póvoas D, Germano N, Maltez F. Fatal Case of Progressive Mpox in a Patient with AIDS-Viral Enteropathy and Malabsorption Demanding the Use of Full Parenteral ARV and Endovenous Cidofovir. Infect Dis Rep 2023; 15:171-179. [PMID: 36960970 PMCID: PMC10037604 DOI: 10.3390/idr15020018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
We report a fatal case of disseminated mpox infection that progressed over more than three months in an HIV-infected patient with acquired immunodeficiency syndrome (AIDS). Mucocutaneous, pleuropulmonary, central nervous system, and gastrointestinal involvement was documented. This course of disease resembles progressive vaccinia, a formerly reported disease caused by uncontrolled replication of smallpox vaccination orthopoxviruses in immunosuppressed patients. Severe small bowel involvement jeopardized normal oral tecovirimat and antiretroviral therapy absorption. This problem prompted the use of full parenteral antiretrovirals and endovenous cidofovir. Although a remarkable decrease in HIV viral load occurred in six days, mpox infection continued to progress, and the patient died of septic shock. This case offers new clinical insights on the presentation of severe disease in AIDS patients. Moreover, this case alerts for the need for prompt therapy initiation in patients at risk of ominous clinical progression.
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Affiliation(s)
- João Caria
- Department of Infectious Diseases, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Francisco Vara-Luiz
- Department of Gastroenterology, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Grupo de Patologia Médica, Nutrição e Exercício Clínico (PaMNEC), Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), 2829-511 Almada, Portugal
| | - Inês Maia
- Department of Internal Medicine, Centro Hospitalar Barreiro-Montijo, 2830-003 Barreiro, Portugal
| | - Anneke Joosten
- Department of Internal Medicine, Centro Hospitalar Barreiro-Montijo, 2830-003 Barreiro, Portugal
| | - Luís Val-Flores
- Department of Intensive Care Medicine, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Hélder Pinheiro
- Department of Infectious Diseases, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, 1069-166 Lisboa, Portugal
- Faculdade de Ciências Médica, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal
| | - Diana Póvoas
- Department of Infectious Diseases, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, 1069-166 Lisboa, Portugal
- Instituto Gulbenkian de Ciência, 2780-156 Oeiras, Portugal
| | - Nuno Germano
- Department of Intensive Care Medicine, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Fernando Maltez
- Department of Infectious Diseases, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, 1069-166 Lisboa, Portugal
- Faculdade de Ciências Médica, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, 1600-190 Lisboa, Portugal
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, 1600-190 Lisboa, Portugal
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3
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Caria J, Pinto R, Leal E, Almeida V, Cristóvão G, Gonçalves AC, Torres M, Santos MB, Pinheiro H, Póvoas D, Seixas D, Lino S, Cardoso O, Manata MJ, Virgolino A, Maltez F. Clinical and Epidemiological Features of Hospitalized and Ambulatory Patients with Human Monkeypox Infection: A Retrospective Observational Study in Portugal. Infect Dis Rep 2022; 14:810-823. [PMID: 36412741 PMCID: PMC9680313 DOI: 10.3390/idr14060083] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 12/14/2022] Open
Abstract
Monkeypox, a neglected and re-emergent zoonotic disease caused by monkeypox virus (MPXV) infection, has been endemic in Central and Western Africa for decades. More recently, an outbreak has spread to a global level, occurring in sites with no previous reported cases and being clustered among men who have sex with men, suggesting new modes of transmission. There is an urgent need for research for a better understanding of the genomic evolution and changing epidemiology of the Orthopoxvirus group. Our work aimed to characterize the clinical and epidemiological features of a cohort of patients with MPXV infection in a Portuguese hospital, admitted between 5 May and 26 July 2022. In this retrospective observational study, aggregate data of a case series on the presentation, clinical course, and outcomes of confirmed MPXV infections are reported. The study included 40 men and 1 woman, with a mean age of 37.2 years old; 92.7% identified as men who have sex with men, 90.2% had unprotected sex or sex with multiple or anonymous partners in the previous month, and 39.0% reported to have had sex with an MPXV-confirmed case; 59.5% had previously known human immunodeficiency virus (HIV) infection, all of whom were under antiretroviral therapy, and no patients had acquired immunodeficiency syndrome (AIDS) criteria. About a quarter of patients were observed only a week after symptom onset. All patients had skin or mucosal lesions and the anogenital region was the most frequent lesion site. There were no statistically significant clinical differences between HIV-positive and negative individuals. Four patients were admitted to the inpatient clinic, two of whom had proctitis with difficult-to-manage anal pain. There were no reported deaths. Our findings suggest the sexual route as a relevant mode of transmission of MPXV and confirm the mostly benign presentation of this disease.
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Affiliation(s)
- João Caria
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Raquel Pinto
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Ema Leal
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Vasco Almeida
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Gonçalo Cristóvão
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Ana Catarina Gonçalves
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Margarida Torres
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Maria Beatriz Santos
- Departamento de Medicina Interna, Hospital do Espírito Santo, Ilha Terceira, 9700-049 Angra do Heroísmo, Portugal
| | - Hélder Pinheiro
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal
| | - Diana Póvoas
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Diana Seixas
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Sara Lino
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Orlando Cardoso
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Maria José Manata
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Ana Virgolino
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina da Universidade de Lisboa, 1649-028 Lisboa, Portugal
- Laboratório Associado TERRA, Faculdade de Medicina da Universidade de Lisboa, 1649-028 Lisboa, Portugal
| | - Fernando Maltez
- Departamento de Doenças Infeciosas, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, 1069-166 Lisboa, Portugal
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina da Universidade de Lisboa, 1649-028 Lisboa, Portugal
- Laboratório Associado TERRA, Faculdade de Medicina da Universidade de Lisboa, 1649-028 Lisboa, Portugal
- Correspondence:
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