Exploring the effect of clinical case definitions on influenza vaccine effectiveness estimation at primary care level: Results from the end-of-season 2022-23 VEBIS multicentre study in Europe

BACKGROUND

Within influenza vaccine effectiveness (VE) studies at primary care level with a laboratory-confirmed outcome, clinical case definitions for recruitment of patients can vary. We used the 2022-23 VEBIS primary care European multicentre study end-of-season data to evaluate whether the clinical case definition affected IVE estimates.

METHODS

We estimated VE using a multicentre test-negative case-control design. We measured VE against any influenza and influenza (sub)types, by age group (0-14, 15-64, ≥65 years) and by influenza vaccine target group, using logistic regression. We estimated IVE among patients meeting the European Union (EU) acute respiratory infection (ARI) case definition and among those meeting the EU influenza-like illness (ILI) case definition, including only sites providing information on specific symptoms and recruiting patients using an ARI case definition (as the EU ILI case definition is a subset of the EU ARI one).

RESULTS

We included 24 319 patients meeting the EU ARI case definition, of whom 21 804 patients (90 %) meet the EU ILI case definition, for the overall pooled VE analysis against any influenza. The overall and influenza (sub)type-specific VE varied by ≤2 % between EU ILI and EU ARI populations.

DISCUSSION

Among all analyses, we found similar VE estimates between the EU ILI and EU ARI populations, with few (10%) additional non-ILI ARI patients recruited. These results indicate that VE in the 2022-23 influenza season was not affected by use of a different clinical case definition for recruitment, although we recommend investigating whether this holds true for next seasons.

Effectiveness of XBB.1.5 Monovalent COVID-19 Vaccines During a Period of XBB.1.5 Dominance in EU/EEA Countries, October to November 2023: A VEBIS-EHR Network Study

Using a common protocol across seven countries in the European Union/European Economic Area, we estimated XBB.1.5 monovalent vaccine effectiveness (VE) against COVID-19 hospitalisation and death in booster-eligible ≥ 65-year-olds, during October-November 2023. We linked electronic records to construct retrospective cohorts and used Cox models to estimate adjusted hazard ratios and derive VE. VE for COVID-19 hospitalisation and death was, respectively, 67% (95%CI: 58-74) and 67% (95%CI: 42-81) in 65- to 79-year-olds and 66% (95%CI: 57-73) and 72% (95%CI: 51-85) in ≥ 80-year-olds. Results indicate that periodic vaccination of individuals ≥ 65 years has an ongoing benefit and support current vaccination strategies in the EU/EEA.

COVID-19 vaccine effectiveness against symptomatic infection with SARS-CoV-2 BA.1/BA.2 lineages among adults and adolescents in a multicentre primary care study, Europe, December 2021 to June 2022

BackgroundScarce European data in early 2021 suggested lower vaccine effectiveness (VE) against SARS-CoV-2 Omicron lineages than previous variants.AimWe aimed to estimate primary series (PS) and first booster VE against symptomatic BA.1/BA.2 infection and investigate potential biases.MethodsThis European test-negative multicentre study tested primary care patients with acute respiratory symptoms for SARS-CoV-2 in the BA.1/BA.2-dominant period. We estimated PS and booster VE among adults and adolescents (PS only) for all products combined and for Comirnaty alone, by time since vaccination, age and chronic condition. We investigated potential bias due to correlation between COVID-19 and influenza vaccination and explored effect modification and confounding by prior SARS-CoV-2 infection.ResultsAmong adults, PS VE was 37% (95% CI: 24-47%) overall and 60% (95% CI: 44-72%), 43% (95% CI: 26-55%) and 29% (95% CI: 13-43%) < 90, 90-179 and ≥ 180 days post vaccination, respectively. Booster VE was 42% (95% CI: 32-51%) overall and 56% (95% CI: 47-64%), 22% (95% CI: 2-38%) and 3% (95% CI: -78% to 48%), respectively. Primary series VE was similar among adolescents. Restricting analyses to Comirnaty had little impact. Vaccine effectiveness was higher among older adults. There was no signal of bias due to correlation between COVID-19 and influenza vaccination. Confounding by previous infection was low, but sample size precluded definite assessment of effect modification.ConclusionPrimary series and booster VE against symptomatic infection with BA.1/BA.2 ranged from 37% to 42%, with similar waning post vaccination. Comprehensive data on previous SARS-CoV-2 infection would help disentangle vaccine- and infection-induced immunity.

Interim 2023/24 influenza A vaccine effectiveness: VEBIS European primary care and hospital multicentre studies, September 2023 to January 2024

Influenza A viruses circulated in Europe from September 2023 to January 2024, with influenza A(H1N1)pdm09 predominance. We provide interim 2023/24 influenza vaccine effectiveness (IVE) estimates from two European studies, covering 10 countries across primary care (EU-PC) and hospital (EU-H) settings. Interim IVE was higher against A(H1N1)pdm09 than A(H3N2): EU-PC influenza A(H1N1)pdm09 IVE was 53% (95% CI: 41 to 63) and 30% (95% CI: -3 to 54) against influenza A(H3N2). For EU-H, these were 44% (95% CI: 30 to 55) and 14% (95% CI: -32 to 43), respectively.

Vaccine effectiveness against influenza hospitalisation in adults during the 2022/2023 mixed season of influenza A(H1N1)pdm09, A(H3N2) and B circulation, Europe: VEBIS SARI VE hospital network

We conducted a multicentre hospital-based test-negative case-control study to measure vaccine effectiveness (VE) against PCR-confirmed influenza in adult patients with severe acute respiratory infection (SARI) during the 2022/2023 influenza season in Europe. Among 5547 SARI patients ≥18 years, 2963 (53%) were vaccinated against influenza. Overall VE against influenza A(H1N1)pdm09 was 11% (95% CI: -23-36); 20% (95% CI: -4-39) against A(H3N2) and 56% (95% CI: 22-75) against B. During the 2022/2023 season, while VE against hospitalisation with influenza B was >55%, it was ≤20% for influenza A subtypes. While influenza vaccination should be a priority for future seasons, improved vaccines against influenza are needed.

Health beliefs and attitudes toward Influenza and COVID-19 vaccination in Portugal: a study using a mixed-method approach

Introduction

Vaccination is one of the most effective population strategies to prevent infectious diseases and mitigate pandemics, and it is important to understand vaccine uptake determinants since vaccine hesitancy has been increasing for the past few decades. The Health Belief Model (HBM) has been widely used for understanding vaccination behavior. The current study aimed to assess influenza vaccine (IV) non-uptake and attitudes toward COVID-19 vaccination, two important respiratory diseases with similar symptoms, and routes of transmission in the Portuguese population.

Methods

We conducted a cross-sectional study using a panel sample of randomly chosen Portuguese households. A total of 1,050 individuals aged 18 years and over responded to a telephone or online questionnaire. Through a mixed-method approach, we employed thematic content analysis to describe reasons for not taking the IV, considering the HBM dimensions, and quantitative statistical analysis to estimate IV and COVID-19 vaccine coverage.

Results

The IV uptake for the overall population was 30.7% (CI 95%: 26.5, 35.2). Susceptibility was found to be a main factor for IV non-uptake, followed by barriers, such as stock availability and fear of adverse effects. The uptake of the COVID-19 vaccine was very high in the study population (83.1%, CI 95%: 13.6%-20.9%). There was a high perception of COVID-19-associated severity and fear of the consequences. Individuals who reported IV uptake seemed to perceive a higher severity of COVID-19 and a higher benefit of taking the COVID-19 vaccine for severe complications.

Discussion

Thus, the population does not seem to consider influenza to be a health risk, as opposed to COVID-19, which is considered to be a possibly severe disease. The association between IV uptake and COVID-19 perceptions highlights that an overall attitude toward vaccination in general may be an important individual determinant.

Effectiveness of the adapted bivalent mRNA COVID-19 vaccines against hospitalisation in individuals aged ≥ 60 years during the Omicron XBB lineage-predominant period: VEBIS SARI VE network, Europe, February to August, 2023

We conducted a multicentre hospital-based test-negative case-control study to measure the effectiveness of adapted bivalent COVID-19 mRNA vaccines against PCR-confirmed SARS-CoV-2 infection during the Omicron XBB lineage-predominant period in patients aged ≥ 60 years with severe acute respiratory infection from five countries in Europe. Bivalent vaccines provided short-term additional protection compared with those vaccinated > 6 months before the campaign: from 80% (95% CI: 50 to 94) for 14-89 days post-vaccination, 15% (95% CI: -12 to 35) at 90-179 days, and lower to no effect thereafter.

End of season 2022/2023 quadrivalent influenza vaccine effectiveness in preventing influenza in primary care in Portugal

Using a test-negative case-control design, we aim to estimate influenza vaccine effectiveness (VE) against medically attended laboratory-confirmed influenza in Portugal in 2022/2023 season. Between week 41/2022 and week 14/2023, data on 592 patients with influenza-like illness aged 18 or more years old were collected by the national sentinel influenza surveillance system in primary care settings. Of those, 218 were positive for influenza and 374 were negative controls. We estimated seasonal influenza VE as (1-odds ratio)*100% of being vaccinated in laboratory-confirmed influenza cases vs. negative controls using logistic regression model adjusted for age group, sex, presence of chronic conditions, and month of symptoms onset. The seasonal VE was 59.3% (95% confidence interval (CI): 27.3 to 77.3) against any laboratory-confirmed influenza and not statistically significant 44.5% (95% CI: -5.6 to 70.8) against influenza A (H3N2). In the 2022/2023 season, characterized by early and low influenza activity and predominant A (H3N2) circulation, vaccination provided a moderate protection against medically attended laboratory-confirmed influenza in primary care.

Vaccine effectiveness against COVID-19 hospitalisation in adults (≥ 20 years) during Omicron-dominant circulation: I-MOVE-COVID-19 and VEBIS SARI VE networks, Europe, 2021 to 2022

IntroductionThe I-MOVE-COVID-19 and VEBIS hospital networks have been measuring COVID-19 vaccine effectiveness (VE) in participating European countries since early 2021.AimWe aimed to measure VE against PCR-confirmed SARS-CoV-2 in patients ≥ 20 years hospitalised with severe acute respiratory infection (SARI) from December 2021 to July 2022 (Omicron-dominant period).MethodsIn both networks, 46 hospitals (13 countries) follow a similar test-negative case-control protocol. We defined complete primary series vaccination (PSV) and first booster dose vaccination as last dose of either vaccine received ≥ 14 days before symptom onset (stratifying first booster into received < 150 and ≥ 150 days after last PSV dose). We measured VE overall, by vaccine category/product, age group and time since first mRNA booster dose, adjusting by site as a fixed effect, and by swab date, age, sex, and presence/absence of at least one commonly collected chronic condition.ResultsWe included 2,779 cases and 2,362 controls. The VE of all vaccine products combined against hospitalisation for laboratory-confirmed SARS-CoV-2 was 43% (95% CI: 29-54) for complete PSV (with last dose received ≥ 150 days before onset), while it was 59% (95% CI: 51-66) after addition of one booster dose. The VE was 85% (95% CI: 78-89), 70% (95% CI: 61-77) and 36% (95% CI: 17-51) for those with onset 14-59 days, 60-119 days and 120-179 days after booster vaccination, respectively.ConclusionsOur results suggest that, during the Omicron period, observed VE against SARI hospitalisation improved with first mRNA booster dose, particularly for those having symptom onset < 120 days after first booster dose.

Impact of acute exacerbations of COPD on patients' health status beyond pulmonary function: A scoping review

This scoping review summarized the evidence regarding the impact of acute exacerbations of COPD (AECOPD) on patients' health status beyond pulmonary function. PubMed, Embase, and Web of Science were searched. Prospective cohort studies assessing the health status of patients with COPD in a stable phase of the disease and after a follow-up period (where at least one AECOPD occurred) were included. An integrated assessment framework of health status (i.e., physiological functioning, complaints, functional impairment, quality of life) was used. Twenty-two studies were included. AECOPD acutely affected exercise tolerance, quadriceps muscle strength, physical activity levels, symptoms of dyspnoea and fatigue, and impact of the disease. Long-term effects on quadriceps muscle strength, symptoms of dyspnoea and depression, and quality of life were found. Repeated exacerbations negatively impacted the fat-free mass, levels of dyspnoea, impact of the disease and quality of life. Conflicting evidence was found regarding the impact of repeated exacerbations on exercise tolerance and physical activity levels. AECOPD have well-established acute and long-term adverse effects on health status beyond pulmonary function; nevertheless, the recovery trajectory and the impact of repeated exacerbations are still poorly studied. Further prospective research is recommended to draw firm conclusions on these aspects.

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, 2021

IntroductionTwo large multicentre European hospital networks have estimated vaccine effectiveness (VE) against COVID-19 since 2021.AimWe 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.MethodsForty-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.ResultsWe 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.ConclusionsOur 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%.

Impact of Lifting Mask Mandates on COVID-19 Incidence and Mortality in Portugal: An Ecological Study

INTRODUCTION

The use of face masks in public was one of several COVID-19 non-pharmaceutical interventions adopted to mitigate the pandemic in Portugal. The aim of this study was to evaluate the impact of lifting the mask mandate on the April 22, 2022 on COVID-19 incidence and mortality in mainland Portugal and in the Azores. As a secondary objective, we aimed to evaluate the evolution of COVID-19 cases in a setting without a mask mandate (Azores islands) and in a setting with a mask mandate (Madeira islands).

MATERIAL AND METHODS

Surveillance data on laboratory-confirmed COVID-19 cases and COVID-19 deaths were used to conduct an interrupted time series analysis to estimate changes in daily incidence and deaths during a mask mandate period (28th March - 21st April 2022) and during a post-mask mandate period (22nd April - 15th May 2022), in mainland Portugal and the Azores. In a second phase, for each group of islands, we fitted a negative binomial regression model, with daily COVID-19 incident cases as the primary outcome of interest, and relative frequency of Omicron BA.5 lineage as explanatory variable.

RESULTS

Significant changes in trends were observed for the overall incidence rate and COVID-19 deaths; increasing trends were observed for COVID-19 incidence and deaths in the post mandate period [5.3% per day; incidence rate ratio (IRR): 1.053; 95% confidence interval (CI): 1.029 - 1.078] and [3.2% per day; mortality rate ratio (MRR): 1.032; 95% CI: 1.003 - 1.062], respectively. For every unit increase in the percentage of Omicron BA.5 lineage there was a 1.5% increase per day (IRR: 1.015; 95% CI: 1.006 - 1.024) in COVID-19 incidence rate in the Azores islands, while for Madeira islands an increase of 0.05% COVID-19 cases per day was observed (IRR: 1.005; 95% CI: 1.000 - 1.010).

CONCLUSION

Lifting the mask mandate in Portugal was associated with an increase in COVID-19 incidence and deaths, thus highlighting the positive effect of face mask policies in preventing respiratory virus transmission and saving lives.

Parents of Children Diagnosed with Congenital Anomalies or Cerebral Palsy: Identifying Needs in Interaction with Healthcare Services

The changes deriving from the birth of a child with a congenital anomaly (CA) or cerebral palsy (CP) imply, in many cases, an increased interaction with health services. A cross-sectional descriptive study was conducted with a convenience sample of parents of children diagnosed with four groups of CA (severe heart anomalies, spina bifida, orofacial clefts, and Down syndrome) and/or CP. A semistructured online questionnaire to be answered by parents was sent by web link to focal points of five parent associations and professional institutions. Data were analyzed through thematic content analysis (open-ended questions) and descriptive analysis (closed-ended questions). The results indicate consistency of responses of parents of children diagnosed with different conditions, namely with respect to the perception of health services and professionals. Closed and open-ended responses indicated three main topics in the interaction between health services and parenthood: information, coordinated and integrated responses, and support. The less positive outcomes suggest unmet information needs, while positive aspects include confidence in the care provided and the "training" received from health professionals.

COVID-19 vaccine effectiveness among healthcare workers: a hospital-based cohort study

OBJECTIVES

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.

Comparative Effectiveness of COVID-19 Vaccines in Preventing Infections and Disease Progression from SARS-CoV-2 Omicron BA.5 and BA.2, Portugal

We estimated comparative primary and booster vaccine effectiveness (VE) of SARS-CoV-2 Omicron BA.5 and BA.2 lineages against infection and disease progression. During April-June 2022, we implemented a case-case and cohort study and classified lineages using whole-genome sequencing or spike gene target failure. For the case-case study, we estimated the adjusted odds ratios (aORs) of vaccination using a logistic regression. For the cohort study, we estimated VE against disease progression using a penalized logistic regression. We observed no reduced VE for primary (aOR 1.07 [95% CI 0.93-1.23]) or booster (aOR 0.96 [95% CI 0.84-1.09]) vaccination against BA.5 infection. Among BA.5 case-patients, booster VE against progression to hospitalization was lower than that among BA.2 case-patients (VE 77% [95% CI 49%-90%] vs. VE 93% [95% CI 86%-97%]). Although booster vaccination is less effective against BA.5 than against BA.2, it offers substantial protection against progression from BA.5 infection to severe disease.

Measuring the impact of COVID-19 vaccination and immunity waning: A modelling study for Portugal

Vaccination strategies to control COVID-19 have been ongoing worldwide since the end of 2020. Understanding their possible effect is key to prevent future disease spread. Using a modelling approach, this study intends to measure the impact of the COVID-19 Portuguese vaccination strategy on the effective reproduction number and explore three scenarios for vaccine effectiveness waning. Namely, the no-immunity-loss, 1-year and 3-years of immunity duration scenarios. We adapted an age-structured SEIR deterministic model and used Portuguese hospitalisation data for the model calibration. Results show that, although the Portuguese vaccination plan had a substantial impact in reducing overall transmission, it might not be sufficient to control disease spread. A significant vaccination coverage of those above 5 years old, a vaccine effectiveness against disease of at least 80% and softer non-pharmaceutical interventions (NPIs), such as mask usage and social distancing, would be necessary to control disease spread in the worst scenario considered. The immunity duration scenario of 1-year displays a resurgence of COVID-19 hospitalisations by the end of 2021, the same is observed in 3-year scenario although with a lower magnitude. The no-immunity-loss scenario presents a low increase in hospitalisations. In both the 1-year and 3-year scenarios, a vaccination boost of those above 65 years old would result in a 53% and 38% peak reduction of non-ICU hospitalisations, respectively. These results suggest that NPIs should not be fully phased-out but instead be combined with a fast booster vaccination strategy to reduce healthcare burden.

Influenza vaccine effectiveness against influenza A subtypes in Europe: Results from the 2021-2022 I-MOVE primary care multicentre study

BACKGROUND

In 2021-2022, influenza A viruses dominated in Europe. The I-MOVE primary care network conducted a multicentre test-negative study to measure influenza vaccine effectiveness (VE).

METHODS

Primary care practitioners collected information on patients presenting with acute respiratory infection. Cases were influenza A(H3N2) or A(H1N1)pdm09 RT-PCR positive, and controls were influenza virus negative. We calculated VE using logistic regression, adjusting for study site, age, sex, onset date, and presence of chronic conditions.

RESULTS

Between week 40 2021 and week 20 2022, we included over 11 000 patients of whom 253 and 1595 were positive for influenza A(H1N1)pdm09 and A(H3N2), respectively. Overall VE against influenza A(H1N1)pdm09 was 75% (95% CI: 43-89) and 81% (95% CI: 45-93) among those aged 15-64 years. Overall VE against influenza A(H3N2) was 29% (95% CI: 12-42) and 25% (95% CI: -41 to 61), 33% (95% CI: 14-49), and 26% (95% CI: -22 to 55) among those aged 0-14, 15-64, and over 65 years, respectively. The A(H3N2) VE among the influenza vaccination target group was 20% (95% CI: -6 to 39). All 53 sequenced A(H1N1)pdm09 viruses belonged to clade 6B.1A.5a.1. Among 410 sequenced influenza A(H3N2) viruses, all but eight belonged to clade 3C.2a1b.2a.2.

DISCUSSION

Despite antigenic mismatch between vaccine and circulating strains for influenza A(H3N2) and A(H1N1)pdm09, 2021-2022 VE estimates against circulating influenza A(H1N1)pdm09 were the highest within the I-MOVE network since the 2009 influenza pandemic. VE against A(H3N2) was lower than A(H1N1)pdm09, but at least one in five individuals vaccinated against influenza were protected against presentation to primary care with laboratory-confirmed influenza.

Project SELfit: training socio-emotional skills in a school environment in Porto

Issue/Problem

Mental disorders are the main cause of years lived with disability (YLD) in 5-14-year-old people around the world, in Western Europe, and particularly in Portugal. Young people who experience anxiety during childhood have a 3,5-fold likelihood of suffering from depression or anxiety during adulthood. COVID-19 has aggravated this situation, namely regarding socio-emotional competencies.

Description of the problem

SELfit, a project based on the Socio-emotional learning (SEL) methodology, aims promoting mental health, by training teachers and community nurses to develop socio-emotional skills in students from primary schools. The project includes a theoretical and a practical/training session, and monthly supervision sessions by a team that includes a psychologist, a public health doctor and public health nurses. The period of implementation is between February to July 2022.

Results

A total of 8 community nurses and 13 teachers from 3 primary schools in Porto enrolled in this project, which corresponds to a total around 272 students from 5 to 8-year-old. Knowledge of nurses and teachers regarding mental health literacy, and social emotional learning was assessed, before and after the theoretical session. The mean percentage of correct answers before was 49% (54% regarding nurses and 45% teachers) compared to 84% (92% regarding nurses and 78% teachers) after. Concerning socio-emotional skills of the primary school students, possible improvement will be evaluated at the end of the project (July 2022).

Lessons

Mental health literacy and social emotional learning knowledge increased 35%, which highlights the importance of these theoretical sessions promoting mental health literacy. By the end of this project, it is expected to exist an improvement on socio-emotional skills of the primary school students. This is a very important project, expected to be implement and replicated in other schools in Porto and in Portugal.

Key messages

• Mental disorders are the main cause of years lost due to disability (YLD) in primary school students in Portugal; hence, it was chosen for this mental health promotion project.

• This is a pioneer project in Porto, involving both community nurses and primary teachers, in which all are involved in training and promoting social-emotional learning in a school context.

Impact of booster vaccination on COVID-19 outcomes in Portuguese population aged 80 or more years old

Background

Vaccination is essential to control SARS-CoV-2 transmission and complications. The study aimed to estimate the number of SARS-CoV-2 infections, COVID-19 hospitalizations and deaths averted by booster vaccination in Portuguese population aged 80 or more years old.

Methods

We developed an ecological study for the period of the Omicron variant of concern predominance (week 2 to week 16, 2022). Data on vaccine coverage and effectiveness, and number of events of different severity reported to the national COVID-19 surveillance system were used to estimate the number of averted events, prevented fraction and number needed to vaccinate. Uncertainty intervals (UI) were obtained using Monte Carlo simulations.

Results

By week 2 2022, vaccination coverage in the target population reached 91.2%. Booster vaccine effectiveness was 4.1% (CI95%: -0.1 to 9.0), 87.5% (CI95%: 84.9 to 89.7) and 83.2 (CI95%: 80.3 to 85.7) against infection, hospitalization and death, respectively. During the study period, 70862 SARS-CoV-2 infections, 2697 COVID-19 hospitalizations and 2106 deaths were reported. Booster vaccination averted 2731 (UI95%: -298 to 5838) infections, 10629 (UI95%: 9173 to 12127) hospitalizations and 6608 (UI95%: 5725 to 7546) COVID-19 related deaths among individuals aged 80 years or more resident in Portugal. Prevented fractions were 3.7% (UI95%: 0 to 7.6%), 79.7% (UI95%: 77.3 to 81.7%) and 75.8% (UI95%: 73.2 to 78.1%), respectively. It would require to vaccinate 59 individuals (UI95%: 52 to 69) to prevent one hospitalization and 94 individuals (UI95%: 82 to 109) to prevent one death in the target population.

Conclusions

The booster vaccination strategy had considerable impact on preventing severe outcomes in the Portuguese population aged 80 and more years old.

Key messages

• High vaccine coverage combined with high vaccine effectiveness resulted in considerable reduction of severe COVID-19 outcomes.

• Information on number of outcomes of different severity levels averted by COVID-19 booster vaccination allows to strength public health communication.

Excess costs of multiple sclerosis: A register-based study in Sweden

Background and Objective

Population-based estimates of the socioeconomic burden of multiple sclerosis (MS) are limited, especially regarding primary healthcare. This study aimed to estimate the excess costs of people with MS that could be attributed to MS, including primary healthcare.

Methods

An observational study was conducted of the 2806 working-aged people with MS in Stockholm, Sweden and 28,060 propensity score matched references without MS. Register-based resource use was quantified for 2018. Annual healthcare costs (primary, specialised outpatient, and inpatient healthcare visits along with prescribed drugs) and productivity losses (operationalised by sickness absence and disability pension days) were quantified using bottom-up costing. Costs were compared between the people with MS and references with independent t-tests with bootstrapped 95% confidence intervals (CIs) to isolate the excess costs of MS.

Results

The mean annual excess costs of MS for healthcare were €7381 (95% CI: 6991-7816) per person with MS with disease modifying therapies as the largest component (€4262, 95% CI: 4026-4497). There was a mean annual excess cost for primary healthcare of €695 (95% CI: 585-832) per person with MS, comprising 9.4% of the excess healthcare costs of MS. The mean annual excess costs of MS for productivity losses were €13,173 (95% CI: 12,325-14,019) per person with MS, predominately from disability pension (79.3%).

Conclusions

The socioeconomic burden of MS in Sweden from healthcare consumption and productivity losses was quantified, updating knowledge on the cost structure of the substantial excess costs of MS.

Key messages

• Primary healthcare contributes around a tenth of the excess healthcare costs of MS in Sweden, primarily owing to contacts with healthcare professionals other than physicians.

• Overall, the excess costs of MS in Sweden from lost production are larger in magnitude than the excess costs for healthcare consumption.

COVID-19 mRNA vaccine effectiveness (second and first booster dose) against hospitalisation and death during Omicron BA.5 circulation: cohort study based on electronic health records, Portugal, May to July 2022

We measured vaccine effectiveness (VE) against COVID-19-related severe outcomes in elderly people in Portugal between May and July 2022. In ≥ 80 year-olds, the second booster dose VE was 81% (95% CI: 75–85) and 82% (95% CI: 77–85), respectively, against COVID-19-related hospitalisation and death. The first booster dose VE was 63% (95% CI: 55–70) in ≥ 80 year-olds and 74% (95% CI: 66–80) in 60–79 year-olds against hospitalisation, and 63% (95% CI: 57–69) and 65% (95% CI: 54–74) against death.

COVID-19 vaccine effectiveness against symptomatic SARS-CoV-2 infections, COVID-19 related hospitalizations and deaths, among individuals aged ≥65 years in Portugal: A cohort study based on data-linkage of national registries February-September 2021

Background

Using data from electronic health registries, this study intended to estimate the COVID-19 vaccine effectiveness (VE) in the population aged 65 years and more, against symptomatic infection, COVID-19-related hospitalizations, and deaths, overall and by time since complete vaccination for the period February to September 2021

Methods

We established a cohort of individuals aged 65 and more years old, resident in Portugal mainland, using the National Health Service User number to link eight electronic health registries. Outcomes included were symptomatic SARS-CoV-2 infections, COVID-19-related hospitalizations or deaths. The exposures of interest were the mRNA vaccines (Comirnaty or Spikevax) and the viral vector (Vaxzevria) vaccine. Complete schedule VE was estimated as one minus the confounder adjusted hazard ratio, for each outcome, estimated by time-dependent Cox regression with time-dependent vaccine exposure.

Results

For the cohort of individuals aged 65–79 years, complete scheme VE against symptomatic infection varied 43 (95%CI: 37–49) (Vaxzevria) and 65 (95%CI: 62–68) (mRNA vaccines). This estimate was slightly lower in the ≥80 years cohort (53, 95%CI: 45–60) for mRNA vaccines). VE against COVID-19 hospitalization varied between 89% (95%CI: 52–94) for Vaxzevria and 95% (95%CI: 93–97) for mRNA vaccines for the cohort aged 65–79 years and was 76% (95%CI: 67–83) for mRNA vaccines in the ≥80 years cohort. High VE against COVID-19-related deaths was estimated, for both vaccine types, 95% and 81 (95%CI:76–86) for the 65–79 years and the ≥80 years cohort, respectively. We observed a significant waning of VE against symptomatic infection, with VE estimates reaching approximately 34% for both vaccine types and cohorts. Significant waning was observed for the COVID-19 hospitalizations in the ≥80 years cohort (decay from 83% (95%CI:68 to 91) 14–41 days to 63% (95%CI:37 to 78) 124 days after mRNA second dose). No significant waning effect was observed for COVID-19-related deaths in the period of follow-up of either cohort.

Conclusions

In a population with a high risk of SARS-CoV-2 complications, we observed higher overall VE estimates against more severe outcomes for both age cohorts when compared to symptomatic infections. Considering the analysis of VE according to time since complete vaccination, the results showed a waning effect for both age cohorts in symptomatic infection and COVID-19 hospitalization for the 80 and more years cohort.

Effectiveness of complete primary vaccination against COVID-19 at primary care and community level during predominant Delta circulation in Europe: multicentre analysis, I-MOVE-COVID-19 and ECDC networks, July to August 2021

IntroductionIn July and August 2021, the SARS-CoV-2 Delta variant dominated in Europe.AimUsing a multicentre test-negative study, we measured COVID-19 vaccine effectiveness (VE) against symptomatic infection.MethodsIndividuals with COVID-19 or acute respiratory symptoms at primary care/community level in 10 European countries were tested for SARS-CoV-2. We measured complete primary course overall VE by vaccine brand and by time since vaccination.ResultsOverall VE was 74% (95% CI: 69-79), 76% (95% CI: 71-80), 63% (95% CI: 48-75) and 63% (95% CI: 16-83) among those aged 30-44, 45-59, 60-74 and ≥ 75 years, respectively. VE among those aged 30-59 years was 78% (95% CI: 75-81), 66% (95% CI: 58-73), 91% (95% CI: 87-94) and 52% (95% CI: 40-61), for Comirnaty, Vaxzevria, Spikevax and COVID-19 Vaccine Janssen, respectively. VE among people 60 years and older was 67% (95% CI: 52-77), 65% (95% CI: 48-76) and 83% (95% CI: 64-92) for Comirnaty, Vaxzevria and Spikevax, respectively. Comirnaty VE among those aged 30-59 years was 87% (95% CI: 83-89) at 14-29 days and 65% (95% CI: 56-71%) at ≥ 90 days between vaccination and onset of symptoms.ConclusionsVE against symptomatic infection with the SARS-CoV-2 Delta variant varied among brands, ranging from 52% to 91%. While some waning of the vaccine effect may be present (sample size limited this analysis to only Comirnaty), protection was 65% at 90 days or more between vaccination and onset.

Using Social Media as a Research Tool for a Bespoke Web-Based Platform for Stakeholders of Children With Congenital Anomalies: Development Study

BACKGROUND

Limited research evidence exists on the development of web-based platforms for reciprocal communication, coproduction research, and dissemination of information among parents, professionals, and researchers. This paper provides learning and the outcomes of setting up a bespoke web-based platform using social media.

OBJECTIVE

This study aims to explore the establishment of a web-based, multicontextual research communication platform for parents and stakeholders of children with congenital anomalies using social media and to identify associated research and ethical and technical challenges.

METHODS

The ConnectEpeople e-forum was developed using social media platforms with a stakeholder engagement process. A multilevel approach was implemented for reciprocal engagement between parents of children with congenital anomalies, researchers, health care professionals, and other stakeholders using private and invisible and public Facebook groups, closed Twitter groups, and YouTube. Ethical approval was obtained from Ulster University.

RESULTS

Nonprofit organizations (N=128) were invited to engage with an initial response rate of 16.4% (21/128). Of the 105 parents contacted, 32 entered the private and invisible Facebook groups to participate in the coproduction research. Public Facebook page followers rose to 215, a total of 22 posts had an engagement of >10%, and 34 posts had a reach of over 100. Webinars included requested information on childhood milestones and behavior. YouTube coverage included 106 ConnectEpeople videos with 28,708 impressions. Project information was obtained from 35 countries. The highest Facebook activity occurred during the early morning hours. Achievement of these results required dedicated time management, social media expertise, creativity, and sharing knowledge to curate valuable content.

CONCLUSIONS

Building and maintaining a multilayered online forum for coproduction and information sharing is challenging. Technical considerations include understanding the functionality and versatility of social media metrics. Social media offers valuable, easily accessible, quantitative, and qualitative data that can drive the reciprocal process of forum development. The identification and integration of the needs of the ConnectEpeople e-forum was a key driver in the dissemination of useful, meaningful, and accessible information. The necessary dedicated administration to respond to requests and posts and collate data required significant time and effort. Participant safety, the development of trust, and the maintenance of confidentiality were major ethical considerations. Discussions on social media platforms enabled parents to support each other and their children. Social media platforms are particularly useful in identifying common family needs related to early childhood development. This research approach was challenging but resulted in valuable outputs requiring further application and testing. This may be of particular importance in response to COVID-19 or future pandemics. Incorporating flexible, adaptable social media strategies into research projects is recommended to develop effective platforms for collaborative and impactful research and dissemination.

Sickness absence and disability pension within different employment status in multiple sclerosis

Introduction

Limitations associated with Multiple Sclerosis (MS) can restrain work capacity and productivity, reducing the possibility to remain in work. Whilst access to sickness compensation might be an option, transitions to other types of employment, such as self-employment, might be considered. We aim to investigate the association of Sickness Absence (SA) and Disability Pension (DP) with employment status among people with multiple sclerosis (PwMS) before and after MS diagnosis compared with people without MS.

Methods

A prospective longitudinal study was conducted using Swedish register data of 2,779 MS patients diagnosed with MS in 2008-2012 in working ages (20-59 years) and 13,863 population-based matched references. Levels of SA and DP one year before and four years after MS diagnosis were analyzed. Risk of annual SA and DP levels of more than 180 days were compared among the MS patients and references and, their different types of employment, by means of Cox proportional hazard models and adjusted for socio-demographic variables and SA and DP before MS diagnosis.

Results

In general, people with MS had higher levels of SA and DP before and shortly after MS diagnosis compared to references. PwMS showed a significantly higher probability of reaching over 180 days of SA (Hazard Ratio [HR]=4.89, 95% Confidence interval [CI]=4.43-5.40) and over 180 days of DP (HR = 6.31, 95% CI = 5.46-7.30)) than the references, regardless of type of employment. Moreover, when compared to employed references, self-employed PwMS had similar likelihood to reach over 180 days of SA than employed PwMS, (HR = 4.27, 95% CI = 3.81-4.77) and (HR = 3.83, 95% CI = 2.73-5.38), respectively. In contrast, self-employed references showed less probability (HR = 0.49, 95% CI = 0.31-0.78) to reach over 180 days of SA compared to the employed references.

Conclusions

In contrast to references, employed and self-employed PwMS had similar probabilities of reaching over 180 days of SA.

Key messages

This study emphasizes that in Sweden also self-employed have access to sickness compensation, independently of employment status condition. Access to sickness compensation is utilized by PwMS.

Trajectories of sickness absence and disability pension by type of occupation in multiple sclerosis

Background

Multiple sclerosis (MS) can impact working life, sickness absence (SA), and disability pension (DP). Different types of occupations involve different demands, which may be associated with trajectories of SA and DP among people with MS (PwMS). We aim to explore if annual levels of SA and DP differ according to type of occupation among PwMS and references. Further, we aim to gain knowledge of how trajectories of SA and DP are associated with type of occupation among PwMS.

Methods

A nationwide Swedish register-based prospective cohort study with six-year follow-up was conducted, including 6,100 individuals with prevalent MS and 38,641 matched population references. Mean annual SA and DP net days during follow-up years were calculated and stratified by type of occupation. Trajectories of SA and DP were identified with group-based trajectory modelling. Multinomial logistic regressions were estimated for associations between identified trajectories and different types of occupations.

Results

An increase of SA and DP over time in all types of occupations was observed in both PwMS and references, with higher levels of SA and DP among PwMS. Managers had the lowest levels of SA and DP in both groups. Three SA and DP trajectory groups were identified: Persistently Low (55.2%), Moderate Increasing (31.9%), and High Increasing (12.8%). Managers (Odds Ratio [OR] 0.37, 95%CI 0.26-0.52) and those working in Science & Technology (OR 0.64, 95% CI 0.50-0.82) had less probability of belonging to the Moderate Increasing group. Similarly, Managers (OR 0.52, 95%CI 0.30-0.89) and Science & Technology (OR 0.58, 95%CI 0.39-0.88) had also less probability of belonging to the High Increasing group.

Conclusions

Our findings suggest that the type of occupation plays a role in the level and course of SA and DP among PwMS.

Key messages

Over time SA and DP levels increased among PwMS regardless of type of occupation. PwMS in Managers or Science and Technology had less probability of belonging to the increasing trajectories.

Assessment of the anterior superior alveolar nerve and its impact on surgery of the lateral nasal wall

BACKGROUND

The anterior superior alveolar nerve (ASAN) plays a major role in innervation of the lateral nasal wall. Its damage during nasal surgery can cause dental paraesthesia and numbness around the upper lip.

METHODOLOGY

Retrospective evaluation of the computed tomographic (CT) scans of 50 consecutive patients analysing 100 sides. We measured the mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve, to the anterior superior alveolar canal and the anterior-posterior distance between the 'shoulder' of the inferior turbinate and the pyriform aperture.

RESULTS

The mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve was 6.4 ± 2.33 mm, with no difference between sides The mean relative height of the shoulder in relation to the anterior superior alveolar nerve canal was 4.78 ± 2.31mm with no significant difference between the two sides. The anterior-posterior distance between the 'shoulder' of inferior turbinate and the pyriform aperture was 6.96± 2.28mm, with no significant difference between the two sides.

CONCLUSIONS

We found the anterior superior alveolar nerve to be a constant landmark in the lateral nasal wall. Therefore, the course of the ASAN should be assessed on a CT scan when a surgical approach through the pyriform aperture or anterior medial wall of the maxillary sinus is planned.

mRNA vaccine effectiveness against COVID-19-related hospitalisations and deaths in older adults: a cohort study based on data linkage of national health registries in Portugal, February to August 2021

Through deterministic data linkage of health registries, mRNA vaccine effectiveness (VE) against COVID-19-related hospitalisations and deaths was measured in 1,880,351 older adults. VE against hospitalisations was 94% (95% confidence interval (CI): 88–97) and 82% (95% CI: 72–89) for those 65–79 and ≥ 80 years old, with no evidence of waning 98 days after dose two. VE against mortality was 96% (95% CI: 92–98) and 81% (95% CI: 74–87) in these two age groups.

Vaccine effectiveness against symptomatic SARS-CoV-2 infection in adults aged 65 years and older in primary care: I-MOVE-COVID-19 project, Europe, December 2020 to May 2021

We measured COVID-19 vaccine effectiveness (VE) against symptomatic SARS-CoV-2 infection at primary care/outpatient level among adults ≥ 65 years old using a multicentre test-negative design in eight European countries. We included 592 SARS-CoV-2 cases and 4,372 test-negative controls in the main analysis. The VE was 62% (95% CI: 45–74) for one dose only and 89% (95% CI: 79–94) for complete vaccination. COVID-19 vaccines provide good protection against COVID-19 presentation at primary care/outpatient level, particularly among fully vaccinated individuals.

No effect modification of influenza virus vaccine effectiveness by age or chronic condition was observed in the 2010/11 to 2017/18 seasons

PURPOSE

Most European influenza vaccine strategies target individuals at higher risk of complications, which include, among others, individuals aged ≥65 years and with chronic conditions. These individuals not only have a high-risk of post-infection complications but also could have lower capacity of acquiring adequate vaccine-induced protection. As such, chronic conditions and age could modify the effect of vaccines. This study aimed at assessing the potential effect modification of influenza vaccine effectiveness (IVE) by age and chronic conditions.

METHODS

We used eight-season data from the Portuguese vaccine effectiveness study. Every season, physicians at primary care units recruited patients with influenza-like illness. Clinical data and swabs were collected for Reverse Transverse Polymerase Chain Reaction (RT-PCR) detection of influenza. Trivalent inactivated IVE was estimated as 1 - odds ratio (OR) of being vaccinated in cases (RT-PCR positive for influenza) versus negative controls. ORs were obtained using a multivariable conditional logistic regression model, paired by week of onset within each season. Confounders were assessed by designing a specific causal diagram. Age (< 65 or ≥65 years) and chronic conditions (diabetes, cardiovascular disease, chronic renal disease, chronic hepatic disease, obesity, chronic respiratory disease, and congenital or acquired immunodeficiency) were studied as effect modifiers by including an interaction term in the regression models. Significance was established at 5%.

RESULTS

Point estimates indicate a higher IVE in the chronic condition strata compared to that in the no chronic condition strata. Regarding age, different results were obtained considering the virus type and (sub)type. When comparing the ≥65 years with the <65 years of age strata, we observed a higher IVE against A(H1N1)pdm09, an equal IVE against A(H3N2) and a lower IVE against B virus. However, all interaction terms were statistically insignificant, and this may be due to a small sample size.

CONCLUSION

The potential effect modification of age or chronic condition was not observed within our study.

Combining self-reported and objectively measured survey data to improve hypertension prevalence estimates: Portuguese experience

BACKGROUND

Accurate data on hypertension is essential to inform decision-making. Hypertension prevalence may be underestimated by population-based surveys due to misclassification of health status by participants. Therefore, adjustment for misclassification bias is required when relying on self-reports. This study aims to quantify misclassification bias in self-reported hypertension prevalence and prevalence ratios in the Portuguese component of the European Health Interview Survey (INS2014), and illustrate application of multiple imputation (MIME) for bias correction using measured high blood pressure data from the first Portuguese health examination survey (INSEF).

METHODS

We assumed that objectively measured hypertension status was missing for INS2014 participants (n = 13,937) and imputed it using INSEF (n = 4910) as auxiliary data. Self-reported, objectively measured and MIME-corrected hypertension prevalence and prevalence ratios (PR) by sex, age group and education were estimated. Bias in self-reported and MIME-corrected estimates were computed using objectively measured INSEF data as a gold-standard.

RESULTS

Self-reported INS2014 data underestimated hypertension prevalence in all population subgroups, with misclassification bias ranging from 5.2 to 18.6 percentage points (pp). After MIME-correction, prevalence estimates increased and became closer to objectively measured ones, with bias reduction to 0 pp - 5.7 pp. Compared to objectively measured INSEF, self-reported INS2014 data considerably underestimated prevalence ratio by sex (PR = 0.8, 95CI = [0.7, 0.9] vs. PR = 1.2, 95CI = [1.1, 1.4]). MIME successfully corrected direction of association with sex in bivariate (PR = 1.1, 95CI = [1.0, 1.3]) and multivariate analyses (PR = 1.2, 95CI = [1.0, 1.3]). Misclassification bias in hypertension prevalence ratios by education and age group were less pronounced and did not require correction in multivariate analyses.

CONCLUSIONS

Our results highlight the importance of misclassification bias analysis in self-reported hypertension. Multiple imputation is a feasible approach to adjust for misclassification bias in prevalence estimates and exposure-outcomes associations in survey data.

Implementing an Influenza Vaccine Effectiveness Study in a Hospital Context in Portugal: The EVA Hospital Project

INTRODUCTION

The project 'Integrated Monitoring of Vaccines in Europe' aimed to measure seasonal influenza vaccine effectiveness against hospitalised adults, aged 65 years and over, with influenza. We describe the protocol implementation in Portugal.

MATERIAL AND METHODS

We implemented a test-negative design, targeting community-dwelling patients aged 65 years old and over hospitalised with severe acute respiratory illness. Patients were reverse transverse-polymerase chain reaction tested for influenza. Cases were those positive for influenza while others were controls. Most variables were collected using hospital medical records. Selection bias was evaluated by comparison with the laboratory influenza test requests database according to demographic characteristics. Crude, season-adjusted influenza vaccine effectiveness was estimated as = 1 - odds ratio, and 95% confidence intervals were obtained by conditional logistical regression, matched with the disease onset month.

RESULTS

The recruitment rate was 37.8%. Most participants (n = 368) were female (55.8%) and aged 80 years old and over (55.8%). This was similar to values for potentially eligible severe acute respiratory illness patients (80 years old and over: 56.8%, female: 56.2%). The proportion of missing values was below 2.5% for 20 variables and above 5% (maximum 11.6%) for six variables. Influenza vaccine effectiveness estimates were 62.1% against AH1pdm09 (95% confidence intervals: -28.1 to 88.8), 14.9% against A(H3N2) (95% confidence intervals: -69.6 to 57.3), 43.6% against B/Yam (95% confidence intervals: -66.2 to 80.8).

DISCUSSION

Given the non-existence of a coded admission database in either participating hospital the selection of severe acute respiratory illness due to clinical features was the feasible one. These results are only valid for the older adult population residing in the catchment area of the two participating hospitals who were admitted to a public hospital with severe influenza or SARI symptoms.

CONCLUSION

Despite the low participation rate, we observed comparable characteristics of participants and eligible severe acute respiratory illness patients. Data quality was high, and influenza vaccine effectiveness results were in accordance with the results of meta-analyses and European season-specific estimates. The final sample size was low, which inhibited obtaining estimates with good precision.

Clinical profile and microbiological aetiology diagnosis in adult patients hospitalized with community-acquired pneumonia

Early introduction of appropriate antibiotherapy is one of the major prognostic-modifying factors in community acquired pneumonia (CAP). Despite established guidelines for empirical therapy, several factors may influence etiology and, consequently, antibiotic choices. The aims of this study were to analyze the etiology of CAP in adults admitted to a northern Portugal University Hospital and evaluate the yield of the different methods used to reach an etiological diagnosis, as well as analyze of the impact of patient demographic and clinical features on CAP etiology. We retrospectively analyzed 1901 cases of CAP with hospitalization. The diagnostic performance increased significantly when blood and sputum cultures were combined with urinary antigen tests. The most frequent etiological agent was Streptococcus pneumoniae (45.7%), except in August, when it was overtaken by gram-negative bacilli (GNB) and Legionella pneumophila infections. Viral infections were almost exclusive to winter and spring. A negative microbiological result was associated with increasing age, non-smoking and lack of both blood/sputum cultures. Younger age was a predictor for S. pneumoniae, Influenza and L. pneumophila infections. Active smoking without any previously known respiratory disease was a risk factor for legionellosis. COPD was associated with Haemophilus influenzae cases, while dementia was typical in GNB and S. aureus patients. Diabetes mellitus (DM) and heart disease were negative predictors of S. pneumoniae and H. influenzae, respectively. P. aeruginosa was an independent risk factor for mortality (OR 13.02, 95% CI 2.94-57.7). This study highlights the importance of a comprehensive microbiological diagnostic workup and provides clues to predicting the most probable CAP causative agents, based on a patient's clinical profile. These may be taken into account when establishing first line antibiotherapy.

Pregnancy outcomes in women with mechanical heart valves

Background

Mechanical heart valves (MHV) and their absolute need for adequate anticoagulation poses a challenge for pregnancy, either due to warfarin fetotoxicity or an increased risk of maternal thromboembolism. This represents a unique patient (P) group where data is scarce and maternal and fetal risks and benefits must be carefully weighed.

Purpose

To assess maternal and perinatal outcomes in women with MHV on different anticoagulant regimens and compare them with patients with other types of valvular heart disease (VHD).

Methods

A retrospective analysis of 131 pregnancies in 83 women with VHD (mean age 26.5±5.6 years) was carried out in a tertiary referral centre from 2000 to 2019. 92 pregnancies with VHD, including 11 with biological prosthetic valves, and 39 pregnancies in 22 P with MHV were identified. The main outcome measures were major maternal complications and perinatal outcome.

Results

MHV implanted were in mitral position (89.7%), aortic (2.6%), or both (7.7%). History of rheumatic heart disease was identified in 16 P (72.7%) and a congenital etiology was present in 2 P (9.1%). 9 P (40.9%) were on warfarine and 13 P (59.1%) on acenocumarol. Regarding anticoagulation strategy, 21 P (65.6%) remained on oral anticoagulation and 10 P (31.3%) had been switched to some form of heparin during part or the entire pregnancy. Mechanical valve thrombosis complicated pregnancy in 4 patients (10.2%), all cases on heparin, and resulted in maternal death in 1 P. MHV P had more hemorrhagic complications (15.4 vs 2.2%, p=0.004) requiring transfusion or surgical revision. MHV P tended to experience more NHYA class worsening demanding initiation or intensification of cardiac medication (17.9 vs 5.4%, p=0.023). Also in the MHV group there was a higher incidence of miscarriage (46.2 vs 12.0%, p≤0.0005), comprising spontaneous abortion (31.6 vs 7.6%, p&lt;0.0005) and fetal malformations (18.4 vs 5.4%, p=0.028), including warfarin embryopathy (10.3 vs 1.1%, p=0.012). The live birth rate was higher in women on heparin compared with those on warfarin (85.9 vs 79.2%, p=0.002). The presence of multivalve disease (p=0.04), mechanical protheses (p&lt;0.001), ACO (p&lt;0.001) and previous impaired LVEF (p=0.02) were related to miscarriage. In multivariate analysis, ACO was the unique independent predictor of unsuccessful pregnancy (p=0.01). Only 29% of the patients with an MHV had a pregnancy free of serious adverse events compared with other types of VHD (81.5%, p&lt;0.0005).

Conclusions

MHV remains a challenging condition for pregnancy with only 29% chance of experiencing an uncomplicated pregnancy with a live birth. The increased morbimortality warrant extensive prepregnancy counseling with prosthesis type discussion,centralization of care and further larger studies to come up with evidence-based recommendations.

Funding Acknowledgement

Type of funding source: None

Influenza burden estimates in Portugal: seasons 2013/14 to 2018/19

Background

Reliable influenza burden estimates are essential for a true understanding of the influenza epidemics' impact; informed decision-making and effective risk communication. This study aimed to estimate the influenza burden in Portugal in 2013/14 - 2018/19 seasons.

Methods

We estimated seasonal influenza burden, ranging from medically attended influenza cases in primary care to influenza-attributable deaths, using surveillance data. Data were collected for influenza like illness (ILI) epidemic periods, determined by the Moving Epidemic Method. Medically attended influenza cases were estimated by multiplying the number of ILI cases in primary care by the percentage of influenza-positive samples. Hospitalized severe acute respiratory infections (SARI) positive for influenza estimates were computed, multiplying the number of SARI by the percentage of influenza-positive samples. To determine influenza-attributable deaths, a Poisson regression model was used.

Results

The median number of medically attended influenza cases in primary care was 33,668 (325.8 cases per 10,000 population), ranging between 21,393 in 2017/18, [Influenza B and A(H1) co-dominance] and 61,768 in 2014/15 [Influenza B and A(H3) co-dominance]. The median number of SARI positive for influenza was 8,724 (84.4 cases per 10,000 population), ranging between 7,099 in 2013/14 [A(H1) and A(H3) co-dominance], and 9,125 in 2014/15. The median number of influenza-attributable deaths was 3,311 (32.0 cases per 10,000 population), ranging between 96 in 2015/16 [A(H1) dominance], and 5,224 in 2014/15.

Conclusions

Higher mortality, and higher rate of medically attended influenza cases, were found in seasons with A(H3) circulation. Little variability was observed in the number of influenza-positive SARI. The relationship between the number of SARI and the number of deaths requires further investigation. This work highlights the need of health surveillance systems for a better understanding of the influenza impact.

Key messages

Lower burden of influenza is found in seasons with A(H1) co-dominance. Higher burden of influenza is found in seasons with A(H3) circulation. Health surveillance systems are essential to provide data for a better understanding of the epidemiology and extent of seasonal influenza.

Descriptive analyse of a case control study in Portugal: identify to prevent

Background

Prenatal exposure to environmental risk factors are one of the known causes of congenital anomalies (CA). In 2015, a cluster of anorectal anomalies, a rare malformation, in Setúbal district raised interest in researchers. The aim of study was to assess the impact of prenatal exposure of the mothers on the occurrence of CA in the offspring.

Methods

A Case-control study (1:2) was implemented between 2016-2019. Newborns with CA (cases) and newborns without CA (controls) are identified and recruited. Parents were personally interviewed by a health professional using a standardized questionnaire. A descriptive analyses was performed and cases and controls were described based on maternal residence during pregnancy. Chi-square test was used to compare cases and controls.

Results

97 cases and 194 controls were identified. There was a male predominance in the case group (60 vs. 34) and no difference in gestational age between case and control groups. The mean birth weight was similar (3115g in cases vs. 3221g in controls). There was no difference related to mean mother's age nor the presence of maternal chronic disease. Smoking had more expression in the case group (21,2% vs. 16,3%). Moita (37,8%) is the municipality with higher frequency of cases. Musculoskeletal anomalies were the most frequent (35.4%), followed by genital (22.2%) and other anomalies (11%). During the study period, five cases with anorectal anomalies were reported, 4 of them born at 2016 and in 3 the mothers residence place was Moita.

Conclusions

In this study, the high proportion of cases from Moita suggests a possible environmental exposure to a teratogenic agent. Also smoking during pregnancy could be a high risk to anorectal anomalies, as suggested in other studies. More investment in public health measures could protect population from harmful environments.

Key messages

Pprenatal exposure to environemental risk factors increase the risk of congenital anomalies. Mothers residence and place of work could be a risk factor to pregnancy.

Bias correction in self-reported high blood pressure prevalence based on objectively measured data

Background

Reliable and precise estimates of high blood pressure (HBP) prevalence are essential to inform decision-making and policies evaluation. Self-reported HBP may be underestimated by surveys due to misclassification of health status by participants. Misclassification may lead to inaccurate inference. We aimed to assess a feasibility of correcting misclassification bias in self-reported HBP in the Portuguese component of the European Health Interview Survey (INS2014) using data on objective blood pressure measurements from a smaller health examination survey (INSEF).

Methods

We assumed that “true” measured HBP status was missing at random for INS2014 participants (n = 13937). Using a multiple imputation method of logistic regression for monotone missing data patterns, HBP was imputed for INS2014 sample. Auxiliary data on measured HBP from INSEF (n = 4910) was used. Crude and corrected HBP prevalence rates stratified by sex and age group were calculated.

Results

HBP prevalence based on INS2014 increased significantly after multiple imputation correction, from 22.0% [CI95%:20.6-23.5%] to 38.8% [35.4-41.9%] for men and from 26.8% [25.3-28.3%] to 33.0% [30.5-35.4%] for women. Corrected estimates were similar to the objectively measured from INSEF, 39.6% for men and 32.7% for women. Corrected HBP prevalence in INS2014 increased from 4.1% [2.9-5.9%] to 7.9% [4.0-11.8%] in 25-34 years old (yo); from 9.3% [7.8-11.0%] to 17.6% [14.0-21.3%] in 35-44 yo; from 22.5% [20.3-24.8%] to 38.7% [34.2-43.2%] in 45-54 yo; from 39.8% [37.2-42.4%] to 53.8% [49.1-58.5%] in 55-64 yo and from 54.3% [51.5-57.1%] to 67.7% [63.1-72.3%] in 65-74 yo. Corrected rates were similar to the obtained by INSEF (5.7%, 17.0%, 35.8%, 54.8% and 71.3%, respectively).

Conclusions

Our results highlight the importance of bias analysis when using self-reported data on HBP. Multiple imputation is a feasible approach to adjust misclassification bias in health outcomes collected by population surveys.

Key messages

The magnitude and direction of misclassification bias in self-reported health outcomes should be investigated. Multiple imputation is a feasible approach to misclassification bias correction in self-reported survey data.

Neural tube defects: how many cases could have been prevented in Portugal?

Neural tube defects (NTD) occurs when the neural tube does not close properly until the 28th day of foetal life. About 70% of NTD can be prevent if women start folic acid (FA) before pregnancy and until the end of 1st trimester. Portugal has this primary prevention since 1998, however the secondary prevention of NTD with TOPFA is still high (80%). The aim of this study is to describe when FA intake was started and estimate the number of cases that would have be prevented if FA intake started before pregnancy as recommended.

A cross-sectional study using data from the National Registry of Congenital Anomalies between 2004-2017 was performed. The temporal evolution of the beginning of FA intake was analysed with Cochran-Armitage test for proportions. The proportion of preventable cases was estimated considering the 70% prevention fraction and the number of NTD cases registered in RENAC that occurred in pregnancies without the recommended FA supplementation.

On average, 13.8% of all women started FA before pregnancy, 46.2% during 1st trimester and 6.1% did not take folic acid. A statistically significant trend (p &lt; 0.001) was observed in the group that started before pregnancy with increase from 6.8% in 2004 to 17.9% in 2017. The prevalence of NTD was 4.2 cases / 10,000 births, ranging from 2 cases / 10,000 births (2007) to 7 cases / 10,000 births (2014). Between women who had a pregnancy with NTD, 16.8% started FA before pregnancy, 42.2% in the 1st trimester and 9.7% did not take the supplement. If all women had started FA before pregnancy, an estimated 202 NTD cases could have been prevented.

In Portugal, the proportion of women who adhere to this measure is very low, similarly to other European countries, compromising the primary prevention of NTD. Perhaps due to the high percentage of TOPFA, the idea that this anomalies continue to affect our children has been lost. Primary prevention of NTDs should be encouraged with measures that promote FA supplementation.

Key messages

Primary prevention of NTD is possible. Proportion of women who adhere to primary prevention is low.

Predictive equations of maximum respiratory mouth pressures: A systematic review

BACKGROUND

Maximum inspiratory (Pimax) and expiratory (Pemax) mouth pressures are commonly used to detect respiratory muscle weakness resorting to predictive equations established for healthy people. There are several predictive equations, but they are widespread in the literature. This study aimed to review the existent predictive equations of maximum inspiratory (Pimax) and expiratory (Pemax) mouth pressures for adults. Additionally, we aimed to identify which ones were generated based on international standards.

METHODS

A systematic review of predictive equations of Pimax and Pemax for healthy adults was conducted. A comprehensive search was performed of Cochrane Library, EBSCO, PubMed, Scopus and Web of Science to identify studies that presented at least one equation for Pimax or Pemax developed for healthy adults. The quality of studies was assessed by two reviewers with the Quality Assessment of Diagnostic Accuracy Studies (Quadas-2).

RESULTS

Risk of bias was high in 8 of the 20 studies included. Forty-two Pimax and 34 Pemax equations were found, mostly using the variables age (n=39), weight (n=20) and height (n=8). These equations explained 3 to 96% of the Pimax/Pemax variance. They were developed with individuals from 11 countries (Portugal not included). Twelve Pimax and eight Pemax equations complied with international standards.

CONCLUSIONS

This review gathered the predictive equations that have been developed for both Pimax and Pemax, however most were generated from unstandardized procedures. Future studies should explore the suitability of these equations for populations for which specific ones are not available, such as the Portuguese population, and develop new equations if necessary.

Performance of surveillance case definitions for respiratory syncytial virus infections through the sentinel influenza surveillance system, Portugal, 2010 to 2018

BackgroundWell-established influenza surveillance systems (ISS) can be used for respiratory syncytial virus (RSV) surveillance. In Portugal, RSV cases are detected through the ISS using the European Union (EU) influenza-like illness (ILI) case definition.AimTo investigate clinical predictors for RSV infection and how three case definitions (EU ILI, a modified EU acute respiratory infection, and one respiratory symptom) performed in detecting RSV infections in Portugal.MethodsThis observational retrospective study used epidemiological and laboratory surveillance data (October 2010-May 2018). Associations between clinical characteristics and RSV detection were analysed using logistic regression. Accuracy of case definitions was assessed through sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). A 0.05 significance level was accepted.ResultsThe study involved 6,523 persons, including 190 (2.9%) RSV cases. Among 183 cases with age information, RSV infection was significantly more frequent among individuals < 5 years (n = 23; 12.6%) and ≥ 65 years (n = 45; 24.6%) compared with other age groups (p < 0.0001). Cough (odds ratio (OR): 2.4; 95% confidence interval (CI): 1.2-6.5) was the best RSV-infection predictor considering all age groups, while shortness of breath was particularly associated with RSV-positivity among ≤ 14 year olds (OR: 6.7; 95% CI: 2.6-17.4 for 0-4 year olds and OR: 6.7; 95% CI: 1.5-28.8 for 5-14 year olds). Systemic symptoms were significantly associated with RSV-negative and influenza-positive cases. None of the case definitions were suitable to detect RSV infections (AUC = 0.51).ConclusionTo avoid underestimating the RSV disease burden, RSV surveillance within the Portuguese sentinel ISS would require a more sensitive case definition than ILI and, even a different case definition according to age.

Impact of influenza vaccination programmes among the elderly population on primary care, Portugal, Spain and the Netherlands: 2015/16 to 2017/18 influenza seasons

Background

To increase the acceptability of influenza vaccine, it is important to quantify the overall benefits of the vaccination programme.

Aim

To assess the impact of influenza vaccination in Portugal, Spain and the Netherlands, we estimated the number of medically attended influenza-confirmed cases (MAICC) in primary care averted in the seasons 2015/16 to 2017/18 among those ≥ 65 years.

Methods

We used an ecological approach to estimate vaccination impact. We compared the number of observed MAICC (n) to the estimated number that would have occurred without the vaccination programme (N). To estimate N, we used: (i) MAICC estimated from influenza surveillance systems, (ii) vaccine coverage, (iii) pooled (sub)type-specific influenza vaccine effectiveness estimates for seasons 2015/16 to 2017/18, weighted by the proportion of virus circulation in each season and country. We estimated the number of MAICC averted (NAE) and the prevented fraction (PF) by the vaccination programme.

Results

The annual average of NAE in the population ≥ 65 years was 33, 58 and 204 MAICC per 100,000 in Portugal, Spain and the Netherlands, respectively. On average, influenza vaccination prevented 10.7%, 10.9% and 14.2% of potential influenza MAICC each season in these countries. The lowest PF was in 2016/17 (4.9–6.1%) with an NAE ranging from 24 to 69 per 100,000.

Conclusions

Our results suggest that influenza vaccination programmes reduced a substantial number of MAICC. Together with studies on hospitalisations and deaths averted by influenza vaccination programmes, this will contribute to the evaluation of the impact of vaccination strategies and strengthen public health communication.

Understanding influenza vaccination among Portuguese elderly: the social ecological framework

This study intended to identify and quantify the social ecological model (SEM) levels associated to seasonal IV uptake in the Portuguese elderly population. Data from the 2014 National Health Survey was restricted to individuals aged 65+ years (n = 5669). Twenty-three independent variables were allocated to the SEM levels: individual, interpersonal, organizational, community and policy. Sex stratified and age adjusted analysis using Poisson regression were performed for each level and for a fitted full model. Relative reduction in pseudo R magnitude measured marginal contribution of each level. For men and women, older groups (85+ vs. 65–69; men, PR = 1.59 and women, PR = 1.56); having 3+ chronic conditions (men, PR = 1.39 and women, PR = 1.35); previous 4 weeks GP and outpatient visits were associated to higher IV uptake. For men, only 2 SEM levels were associated (individual and organizational) while for women the community level was also relevant. Main marginal contribution came from individual (17.9% and 16.3%) and organizational (30.7% and 22.7%) levels. This study highlights the importance of individual characteristics, access and use of health care services for the IV uptake and the sex differential behaviour.

Vaccine effectiveness against influenza A(H3N2) and B among laboratory-confirmed, hospitalised older adults, Europe, 2017-18: A season of B lineage mismatched to the trivalent vaccine

Background

Influenza A(H3N2), A(H1N1)pdm09 and B viruses co‐circulated in Europe in 2017‐18, predominated by influenza B. WHO‐recommended, trivalent vaccine components were lineage‐mismatched for B. The I‐MOVE hospital network measured 2017‐18 seasonal influenza vaccine effectiveness (IVE) against influenza A(H3N2) and B among hospitalised patients (≥65 years) in Europe.

Methods

Following the same generic protocol for test‐negative design, hospital teams in nine countries swabbed patients ≥65 years with recent onset (≤7 days) severe acute respiratory infection (SARI), collecting information on demographics, vaccination status and underlying conditions. Cases were RT‐PCR positive for influenza A(H3N2) or B; controls: negative for any influenza. “Vaccinated” patients had SARI onset >14 days after vaccination. We measured pooled IVE against influenza, adjusted for study site, age, sex, onset date and chronic conditions.

Results

We included 3483 patients: 376 influenza A(H3N2) and 928 B cases, and 2028 controls. Most (>99%) vaccinated patients received the B lineage‐mismatched trivalent vaccine. IVE against influenza A(H3N2) was 24% (95% CI: 2 to 40); 35% (95% CI: 6 to 55) in 65‐ to 79‐year‐olds and 14% (95% CI: −22 to 39) in ≥80‐year‐olds. Against influenza B, IVE was 30% (95% CI: 16 to 41); 37% (95% CI: 19 to 51) in 65‐ to 79‐year‐olds and 19% (95% CI: −7 to 38) in ≥80‐year‐olds.

Conclusions

IVE against influenza B was similar to A(H3N2) in hospitalised older adults, despite trivalent vaccine and circulating B lineage mismatch, suggesting some cross‐protection. IVE was lower in those ≥80 than 65‐79 years. We reinforce the importance of influenza vaccination in older adults as, even with a poorly matched vaccine, it still protects one in three to four of this population from severe influenza.

Impact of national influenza vaccination strategy in severe influenza outcomes among the high-risk Portuguese population

Background

All aged individuals with a chronic condition and those with 65 and more years are at increased risk of severe influenza post-infection complications. There is limited research on cases averted by the yearly vaccination programs in high-risk individuals. The objective was to estimate the impact of trivalent seasonal influenza vaccination on averted hospitalizations and death among the high-risk population in Portugal.

Methods

The impact of trivalent seasonal influenza vaccination was estimated using vaccine coverage, vaccine effectiveness and the number of influenza-related hospitalizations and deaths. The number of averted events (NAE), prevented fraction (PF) and number needed to vaccinate (NVN) were estimated for seasons 2014/15 to 2016/17.

Results

The vaccination strategy averted on average approximately 1833 hospitalizations and 383 deaths per season. Highest NAE was observed in the ≥65 years population (85% of hospitalizations and 95% deaths) and in the 2016/17 season (1957 hospitalizations and 439 deaths). On average, seasonal vaccination prevented 21% of hospitalizations in the population aged 65 and more, and 18.5% in the population with chronic conditions. The vaccination also prevented 29% and 19.5% of deaths in each group of the high-risk population. It would be needed to vaccinate 3360 high-risk individuals, to prevent one hospitalization and 60,471 high-risk individuals to prevent one death.

Conclusion

The yearly influenza vaccination campaigns had a sustained positive benefit for the high-risk population, reducing hospitalizations and deaths. These results can support public health plans toward increased vaccine coverage in high-risk groups.