Is gender equality associated with a longer healthier life? Ecological evidence from 27 European countries.

BACKGROUND: The association between gender equality and higher life expectancies has been described. Yet, little is known about its association with healthy life expectancy (HLE), or which domains are consistently associated with longer and healthier lives. We aimed to study the association between country-level gender equality, its domains and subdomains, with life expectancy and HLE in Europe, from 2013 to 2019. METHODS: We combined life and HLE estimates from Eurostat with the Gender Equality Index and its 'work', 'knowledge', 'money', 'time' and 'power' domains and respective subdomains, for 27 European countries. Associations were estimated using panel data regression analyses adjusted for Gross Domestic Product, healthcare expenditure and Gini coefficient. RESULTS: Higher life and healthy life expectancies were found in country years with higher gender equality, both for men and women. Associations were particularly consistent for the 'work' (ßHLE-men = 0.59; ßHLE-women = 0.59; P < 0.05) and 'power' domains (ßHLE-men = 0.09; ßHLE-women = 0.12, P < 0.01), especially for the 'work participation', 'political' and 'economic power' subdomains. CONCLUSION: These results point to a country-level association between gender equality and life and healthy life expectancies, suggesting that gender disparities in 'work participation' and 'political' and 'economic power' play a role in the health of women and men through their aging course.

Arguments used by proponents and opponents in Brazil's regulatory discussions of e-cigarettes and heated tobacco products.

OBJECTIVES: To identify proponents and opponents of the commercialisation and marketing of e-cigarettes and heated tobacco products (HTPs), identify the arguments used on both sides and compare how the arguments have changed over time, we analysed three policy discussions occurring in 2009, 2018 and 2019. METHODS: We conducted a content analysis of one document and six videos from these discussions, provided on the Brazilian Health Regulatory Agency website, or upon request. RESULTS: The arguments most used by tobacco companies were related to claims that the use of e-cigarettes and HTPs is less harmful than conventional tobacco. Unions that support its commercialisation also argued that lifting the ban would prevent smuggling and guarantee their quality. On the other side, universities, medical and anti-tobacco institutions argued that such devices may have health risks, including the risk of inducing cigarette smoking. In 2009, most arguments belonged to the 'health' theme, while in 2018 and 2019 economic arguments and those related to morals and ethics were frequently used. CONCLUSIONS: Those that supported the commercialisation and marketing of e-cigarettes and HTPs first focused on arguments of harm reduction, while 10 years later the right to access and potential economic consequences also became common. Public health agents and academics must gather evidence to effectively respond to these arguments and discuss these policies, and must prepare themselves to use and respond to arguments related to moral and economic themes.

Covalent Conjugation of Amphotericin B to Hyaluronic Acid: An Injectable Water-Soluble Conjugate with Reduced Toxicity and Anti-Leishmanial Potential.

Amphotericin B (AmB) is a highly hydrophobic drug with significant leishmanicidal activity whose use is limited by its poor water solubility and adverse effects. Polymer-drug conjugates are proposed as a delivery system designed to overcome those limitations while improving drug bioavailability, safety, and activity. Here, AmB was covalently linked to periodate-oxidized hyaluronic acid (HA) (oxidation degree of 30.1 ± 5.6%) via a Schiff base (HA-AmB imine). The conjugate presents high water solubility and self-assembles into particles with a mean size of 88.2 ± 17.6 nm, a negative charge (-28.3 ± 0.9 mV), and a drug content of 17.8 ± 1.4%. Spectroscopic studies revealed the presence of AmB in aggregate and super-aggregated forms in the conjugate, which could explain the significant reduction of the in vitro cytotoxicity and hemolytic activity. The formulation showed not only in vitro anti-leishmanial activity against L. infantum-infected macrophages (IC50 = 0.023 µM) but also against an in vivo infected mouse model, promoting a 1.32- and a 4.98-log10 suppression of the L. infantum burden in the spleens and liver, respectively, without toxic effects. In summary, this study describes the safe and effective use of water-soluble HA-AmB imine conjugates for leishmaniasis treatment.

School tobacco policies and adolescent smoking in six European cities in 2013 and 2016: A school-level longitudinal study.

Assessment of the effectiveness of school tobacco policies (STPs) in reducing adolescent smoking remains inconclusive. Previous studies took insufficient account of different dimensions of STPs, the different views of students and staff, and policy changes over time. This study assessed how a multidimensional STP, as perceived by students and staff, was associated with adolescent smoking over time in six European cities. The SILNE and SILNE-R surveys were conducted among students (n = 18,502) and staff (n = 438) in 38 schools in 2013 and 2016. Three dimensions (comprehensiveness, enforcement, and communication) were assessed and we calculated total STP scores. Multilevel logistic regressions estimated associations of STPs with adolescent smoking on and just outside school premises and with weekly smoking. Further analyses estimated associations between 2013 and 2016 STP changes and smoking outcomes in 2016, controlling for STP and smoking prevalence in 2013. On average, there were few increases in STP scores over time. Greater STP enforcement, as perceived by students, was associated with lower odds of weekly smoking (OR:0.93, 95%CI:0.89-0.97) and of smoking on school premises (OR:0.80, 95%CI:0.72-0.90). Higher total STP scores were associated with lower odds of smoking on school premises (OR:0.76, 95%CI:0.67-0.86), but not of smoking just outside premises or smoking weekly. Greater increases in STP scores over time were associated with lower odds of smoking on school premises in 2016 (OR:0.65, 95%CI:0.47-0.89). Well-enforced STPs may help reduce adolescent smoking at school. Schools should be supported in adopting comprehensive policies that also extend to the surroundings of their premises.

Economic Evaluation of Five Tobacco Control Policies Across Seven European Countries.

INTRODUCTION: Economic evaluations of tobacco control policies targeting adolescents are scarce. Few take into account real-world, large-scale implementation costs; few compare cost-effectiveness of different policies across different countries. We assessed the cost-effectiveness of five tobacco control policies (nonschool bans, including bans on sales to minors, bans on smoking in public places, bans on advertising at points-of-sale, school smoke-free bans, and school education programs), implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. METHODS: Cost-effectiveness estimates were calculated per country and per policy, from the State perspective. Costs were collected by combining quantitative questionnaires with semi-structured interviews on how policies were implemented in each setting, in real practice. Short-term effectiveness was based on the literature, and long-term effectiveness was modeled using the DYNAMO-HIA tool. Discount rates of 3.5% were used for costs and effectiveness. Sensitivity analyses considered 1%-50% short-term effectiveness estimates, highest cost estimates, and undiscounted effectiveness. FINDINGS: Nonschool bans cost up to €253.23 per healthy life year, school smoking bans up to €91.87 per healthy life year, and school education programs up to €481.35 per healthy life year. Cost-effectiveness depended on the costs of implementation, short-term effectiveness, initial smoking rates, dimension of the target population, and weight of smoking in overall mortality and morbidity. CONCLUSIONS: All five policies were highly cost-effective in all countries according to the World Health Organization thresholds for public health interventions. Cost-effectiveness was preserved even when using the highest costs and most conservative effectiveness estimates. IMPLICATIONS: Economic evaluations using real-world data on tobacco control policies implemented at a large scale are scarce, especially considering nonschool bans targeting adolescents. We assessed the cost-effectiveness of five tobacco control policies implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. This study shows that all five policies were highly cost-effective considering the World Health Organization threshold, even when considering the highest costs and most conservative effectiveness estimates.

Cost of youth tobacco-control policies in seven European countries.

BACKGROUND: Tobacco-control policies have been suggested to reduce smoking among adolescents. However, there is limited evidence on the real-world costs of implementation in different settings. In this study, we aimed at estimating the costs of school smoking bans, school prevention programmes and non-school bans (smoking bans in non-educational public settings, bans on sales to minors and bans on point-of-sale advertising), implemented in Finland, Ireland, the Netherlands, Belgium, Germany, Italy and Portugal, for 2016. METHODS: We retrospectively collected costs related to the inspection, monitoring and sanctioning activities related to bans and educational activities related to smoking prevention programmes. We used an 'ingredients-based' approach, identifying each resource used, quantity and unit value for one full year, under the state perspective. Costs were measured at national, regional, local and school-level and were informed by data on how these activities were performed in reality. RESULTS: Purchasing power parities adjusted-costs varied between €0.02 and €0.74 (average €0.24) per person (pp) for bans implemented outside schools. Mean costs of school smoking bans ranged from €3.31 to €34.76 (average €20.60), and mean costs of school educational programmes from €0.75 to €4.65 (average €2.92). CONCLUSIONS: It is feasible to estimate costs of health policies as implemented in different settings. Costs of the tobacco control policies evaluated here depend mainly on the number of person-hours allocated to their implementation, and on the scale of intervention. Non-school bans presented the lowest costs, and the implementation of all policies cost up to €36 pp for 1 year.

Smoking and school absenteeism among 15- to 16-year-old adolescents: a cross-section analysis on 36 European countries.

BACKGROUND: Schools have a crucial role to play in preventing youth smoking. However, the well-known long-term health consequences of youth smoking may be insufficient to convince education stakeholders to devote efforts to implement school-based programmes. However, if youth smoking were to have short-term consequences, this evidence could prompt education stakeholders' action. In this article, we investigate the link between smoking and school absenteeism. METHODS: We used data from the 2011 wave of the European School Survey Project on Alcohol and Other Drugs, on adolescents aged 15-16. We applied logistic models to assess the risk of more than 3 missed school days, by cause, as function of smoking intensity, adjusting for age, sex, socioeconomic status, academic performance, parental involvement and other risk behaviours (alcohol and cannabis consumption). Consistency was assessed by replicating the analyses for each sex and age group and further adjusting for depression and self-esteem. RESULTS: Smoking more than five cigarettes per day was significantly linked to school absenteeism, with a 55% excess risk of missing more than 3 school days per month due to illness (OR = 1.55, 95% CI 1.46-1.64), and a more than two times excess risk due to skipping (OR = 2.29; 95% CI 2.16-2.43). These findings were consistent across age and sex groups. CONCLUSION: We observed an association between smoking intensity and absenteeism among youth in Europe. This implies that, to the extent that this association is causal, school tobacco control policies may reduce the short-term consequences of smoking on adolescents' education and health.

Public smoking ban and socioeconomic inequalities in smoking prevalence and cessation: a cross-sectional population-based study in Geneva, Switzerland (1995-2014).

INTRODUCTION: Smoking bans were suggested to reduce smoking prevalence and increase quit ratio but their equity impact remains unclear. We aimed to characterise the socioeconomic status (SES)-related inequalities in smoking prevalence and quit ratio before and after the implementation of a public smoking ban. METHODS: We included data from 17 544 participants in the population-based cross-sectional Bus Santé study in Geneva, Switzerland, between 1995 and 2014. We considered educational attainment (primary, secondary and tertiary) as a SES indicator. Outcomes were smoking prevalence (proportion of current smokers) and quit ratio (ex-smokers to ever-smokers ratio). We used segmented linear regression to assess the overall impact of smoking ban on outcome trends. We calculated the relative (RII) and slope (SII, absolute difference) indexes of inequality, quantifying disparities between educational groups in outcomes overall (1995-2014), before and after ban implementation (November 2009). RESULTS: Least educated participants displayed higher smoking prevalence (RII=2.04, P<0.001; SII=0.15, P<0.001) and lower quit ratio (RII=0.73, P<0.001; SII=-0.18, P<0.001). As in other studies, smoking ban implementation coincided with a temporary reduction of smoking prevalence (P=0.003) and increase in quit ratio (P=0.02), with a progressive return to preban levels. Inequalities increased (P<0.05) in relative terms for smoking prevalence (RIIbefore=1.84, P<0.001 and RIIafter=3.01, P<0.001) and absolute terms for both outcomes (smoking prevalence: SIIbefore=0.14, P<0.001 and SIIafter=0.19, P<0.001; quit ratio: SIIbefore=-0.15, P<0.001 and SIIafter=-0.27, P<0.001). CONCLUSIONS: Implementation of a public smoking ban coincided with a short-lived decrease in smoking prevalence and increase in quit ratio but also with a widening in SES inequalities in smoking-related outcomes.

Cost-effectiveness of tobacco control policies and programmes targeting adolescents: a systematic review.

Background: Consistent evidence shows the importance of preventing smoking at young ages, when health behaviours are formed, with long-term consequences on health and survival. Although tobacco control policies and programmes targeting adolescents are widely promoted, the cost-effectiveness of such interventions has not been systematically documented. We performed a systematic review on the cost-effectiveness of policies and programmes preventing tobacco consumption targeting adolescents. Methods: We systematically reviewed literature on the (i) cost and effectiveness of (ii) prevention policies targeting (iii) smoking by (iv) adolescents. PubMed, Web of Science, Cochrane, CEA-TUFTS, Health Economic Evaluations, Wiley Online Library, Centre for Reviews and Dissemination Database, the National Institute for Health and Care Excellence and Google Scholar databases were used, and Google search engine was used for other grey literature review. Results: We obtained 793 full-text papers and 19 grey literature documents, from which 16 studies fulfilled the inclusion criteria. Of these, only one was published in the last 5 years, and 15 were performed in high-income countries. Eight analyzed the cost-effectiveness of school-based programmes, five focused on media campaigns and three on legal bans. Policies and programmes were found to be cost-effective in all studies, and both effective and cost-saving in about half of the studies. Conclusions: Evidence is scarce and relatively obsolete, and rarely focused on the evaluation of legal bans. Moreover, no comparisons have been made between different interventions or across different contexts and implementation levels. However, all studies conclude that smoking prevention policies and programmes amongst adolescents are greatly worth their costs.

Corrigendum: Merging Academy and Healthcare in the Public Health Training of Medical Students.

[This corrects the article DOI: 10.1186/s40985-020-00146-1.].

Industries, citizens, and non-governmental organizations' positioning and arguments used in European Union initiatives for alcohol taxation and cross-border regulation.

BACKGROUND: The European region has the highest daily alcohol consumption per capita and a high alcohol-related burden of disease. Policymaking at the European Union level is open to participation by interest groups, from public health organizations to alcohol industry representatives. This study aimed to map the interest groups present in the alcohol taxation and cross-border regulation initiatives and identify which arguments were used to support positions in favor or against them. METHODS: We used qualitative content analysis on the comments submitted on the official European Commission website during the 2017, 2018, 2020, and 2022 participation periods. Interest groups were characterized considering their positioning, and arguments were identified and compared by position and type of initiative. RESULTS: Opponents of changes to the structures of alcohol excise duties and cross-border regulations were mostly representatives of the alcohol and agricultural industries, and the proponents were mostly health-related nongovernmental organizations. Opponents of these initiatives used a wide variety of arguments, from economic and trade to health arguments, while proponents focused mainly on health arguments, such as the effectiveness of alcohol taxation in preventing alcohol-related morbidity and mortality. CONCLUSION: This study highlights the wide range of arguments used by opponents around alcohol control policies, contrasting with the health-centered arguments of proponents. It further shows that there is a lobbying network at the European Union level, combining national and international representatives of industry and non-governmental organizations. These findings provide an opportunity for better preparation for upcoming discussions on alcohol control at national and regional levels.

The relationship between social capital and inflammatory biomarkers in early adulthood: A longitudinal study.

Higher levels of social capital (SC) are associated with better health status. However, there is little evidence of the impact of SC on biological health outcomes in the early ages. To identify the association between SC in adolescence and inflammation levels in early adulthood. Prospective study using data from 2435 participants from the Epidemiological Health Investigation of Teenagers in Porto cohort. SC was assessed at age 17 through a self-administered questionnaire, and high-sensitivity C-reactive protein (hs-CRP) and leucocytes were measured in a fasting blood sample at 17 and 21 years-old. A principal components analysis was performed to identify the domains of SC. Simple linear regressions were performed to assess the association between SC components and inflammatory status at 17 and 21 years old. Pathway analysis was performed to assess the direct, indirect, and total effects of SC on hs-CRP and leucocyte levels. We did not find a significant total effect between SC at 17 years-old and hs-CRP at 21 years-old. However, the Trust/Reciprocity dimension showed a significant direct effect between SC and hs-CRP levels at 21 (ß = -0.065, 95% CI: -0.129; -0.001), as well as a significant total effect (ß = -0.075, 95% CI: -0.139; -0.011). Regarding leucocyte levels, total SC at 17 years-old was associated with leucocytes levels at 21 (ß = -0.115, 95% CI: -0.205; -0.024). Significant direct (ß = -0.104, 95% CI: -0.194; -0.014) and total effect (ß = -0.107, 95% CI: -0.199; -0.015) of Trust/Reciprocity on leucocyte levels were observed. Adolescents with higher SC have a low inflammatory level in early adulthood, especially those with greater levels of trust/reciprocity.

The cytosolic hyperoxidation-sensitive and -robust Leishmania peroxiredoxins cPRX1 and cPRX2 are both dispensable for parasite infectivity.

Typical two-cysteine peroxiredoxins (2-Cys-PRXs) are H2O2-metabolizing enzymes whose activity relies on two cysteine residues. Protists of the family Trypanosomatidae invariably express one cytosolic 2-Cys-PRX (cPRX1). However, the Leishmaniinae sub-family features an additional isoform (cPRX2), almost identical to cPRX1, except for the lack of an elongated C-terminus with a Tyr-Phe (YF) motif. Previously, cytosolic PRXs were considered vital components of the trypanosomatid antioxidant machinery. Here, we shed new light on the properties, functions and relevance of cPRXs from the human pathogen Leishmania infantum. We show first that LicPRX1 is sensitive to inactivation by hyperoxidation, mirroring other YF-containing PRXs participating in redox signaling. Using genetic fusion constructs with roGFP2, we establish that LicPRX1 and LicPRX2 can act as sensors for H2O2 and oxidize protein thiols with implications for signal transduction. Third, we show that while disrupting the LicPRX-encoding genes increases susceptibility of L. infantum promastigotes to external H2O2in vitro, both enzymes are dispensable for the parasites to endure the macrophage respiratory burst, differentiate into amastigotes and initiate in vivo infections. This study introduces a novel perspective on the functions of trypanosomatid cPRXs, exposing their dual roles as both peroxidases and redox sensors. Furthermore, the discovery that Leishmania can adapt to the absence of both enzymes has significant implications for our understanding of Leishmania infections and their treatment. Importantly, it questions the conventional notion that the oxidative response of macrophages during phagocytosis is a major barrier to infection and the suitability of cPRXs as drug targets for leishmaniasis.

2008 economic crisis impact on perinatal and infant mortality in Southern European countries.

INTRODUCTION: The study of crisis events provides important lessons to prepare for upcoming events. The Great Recession's impact on perinatal health in Europe can provide relevant insights into the healthcare and social protection systems' response to the protection of the health of the most vulnerable groups. OBJECTIVE: To assess time trends and international disparities in perinatal mortality rates (PMR) and infant mortality rates (IMR), following the Great Recession, and their association with socioeconomic indicators in Portugal, Greece, Italy and Spain. METHODS: Associations were assessed through generalised linear models for all four countries. A Poisson joinpoint regression model was applied to explore PMR and IMR trend changes between 2000 and 2018. Country disparities were analysed using mixed-effects multilevel models. RESULTS: IMR and PMR have decreased overall in the four selected countries between 2000 and 2018. Still, whereas in Spain, Italy and Portugal the decreasing pace was attenuated after 2009, in Greece a positive trend was found after the 2008 crisis. IMR and PMR were significantly associated with socioeconomic indicators in all four countries. National disparities in the evolution of IMR and PMR were significantly associated with most socioeconomic indicators between 2000 and 2018. CONCLUSION: Our results confirm the impact of the Great Recession on PMR and IMR trends in all four countries, taking recurring associations between macroeconomic cycles, variations in mortality trends, macroeconomic volatility and stagnation of IMR and PMR into account. The association with socioeconomic indicators stresses the need to strengthen social protection and healthcare systems to better protect the population's health from the earliest days.

The influence of the Great Recession on perinatal health-an ecological study on the trend changes and regional differences in Portugal.

Background: Few studies examine the relationship between socioeconomic factors and trends in mortality in high-income European countries. Due to the lack of regional-level data, most recent studies on social inequality in Portugal do not investigate regional differences. This study analyses time trends and regional disparities in the evolution of perinatal mortality (PMR) and infant mortality (IMR) associated with demographic and socioeconomic indicators following Portugal's 2008 economic and financial crisis. Methods: Associations were assessed using generalised linear models. A Poisson joinpoint regression model was applied to identify relevant PMR and IMR changes between 2000 and 2018. Country regional disparities were analysed using Mixed Effect Multilevel models. Findings: IMR and PMR significantly decreased in the pre-crisis period but not in the post-crisis period. The significant differences between regions in IMR and PMR in 2000 were followed by a different evolution of regional IMR after 2008. PMR and IMR were not significantly associated with socioeconomic indicators. A significant positive association with maternal age at first birth was identified. Interpretation: Results confirm the influence of the crisis on PMR and IMR trends in Portugal, taking into account recurring associations between macroeconomic cycles, variations in mortality trends, macroeconomic volatility, and stagnation of IMR and PMR. Regional inequalities confirm the internal variability of the crisis influence and persistent spatial inequalities affecting IMR patterns. Funding: FCT, under the Institute of Public Health of the University of Porto (ISPUP)-EPIUnit (UIDB/04750/2020) and ITR (LA/P/0064/2020), Maastricht University's external PhD programme under the Care and Public Health Research Institute (CAPHRI), and the RECAP preterm project (grant agreement no 733280).

Structure-Activity Relationship Studies of 9-Alkylamino-1,2,3,4-tetrahydroacridines against Leishmania (Leishmania) infantum Promastigotes.

Leishmaniasis is one of the most neglected diseases in modern times, mainly affecting people from developing countries of the tropics, subtropics and the Mediterranean basin, with approximately 350 million people considered at risk of developing this disease. The incidence of human leishmaniasis has increased over the past decades due to failing prevention and therapeutic measures-there are no vaccines and chemotherapy, which is problematic. Acridine derivatives constitute an interesting group of nitrogen-containing heterocyclic compounds associated with numerous bioactivities, with emphasis to their antileishmanial potential. The present work builds on computational studies focusing on a specific enzyme of the parasite, S-adenosylmethionine decarboxylase (AdoMet DC), with several 1,2,3,4-tetrahydro-acridines emerging as potential inhibitors, evidencing this scaffold as a promising building block for novel antileishmanial pharmaceuticals. Thus, several 1,2,3,4-tetrahydroacridine derivatives have been synthesized, their activity against Leishmania (Leishmania) infantum promastigotes evaluated and a structure-activity relationship (SAR) study was developed based on the results obtained. Even though the majority of the 1,2,3,4-tetrahydroacridines evaluated presented high levels of toxicity, the structural information gathered in this work allowed its application with another scaffold (quinoline), leading to the obtention of N1,N12-bis(7-chloroquinolin-4-yl)dodecane-1,12-diamine (12) as a promising novel antileishmanial agent (IC50 = 0.60 ± 0.11 µM, EC50 = 11.69 ± 3.96 µM and TI = 19.48).

Post-traumatic stress disorder in youth exposed to the Syrian conflict: A systematic review and meta-analysis of prevalence and determinants.

A decade of ongoing armed conflict in Syria has damaged the physical and mental health of millions of adults and children. This study aimed to systematically review the prevalence of post-traumatic stress disorder among youth exposed to the Syrian conflict, and understand its individual and contextual determinants. The screening procedure resulted in 26 studies, with a total of 11,400 Syrian children and adolescents. The prevalence was 36% (95% CI (0.29-0.43), p < 0.001). Loss of family members or acquaintances, witnessing violence, and social withdrawal increased the risk of post-traumatic stress disorder, while social trust and social support were protective factors.

What doubts, concerns and fears about COVID-19 emerged during the first wave of the pandemic?

OBJECTIVES: The control of the COVID-19 pandemic depends strongly on effective communication, which must be grounded on the population's perceptions and knowledge. We aimed to analyse the doubts, concerns and fears expressed by the Portuguese population about COVID-19. METHODS: We performed a content analysis of 293 questions submitted to online, radio, newspaper and TV channel forums during the first month of the pandemic in Portugal. RESULTS: Most questions contained doubts (n = 230), especially on how to prevent person-to-person transmission (n = 40) and how to proceed in case of symptoms (n = 37). Concerns and fears were also very commonly expressed (n = 144), mostly about which persons could be considered vulnerable (n = 53) and how to prevent transmission during daily life or normal activities (n = 37). CONCLUSION: As the pandemic evolved and suppression measures were put in place, doubts moved to concerns of vulnerability, quarantine and social isolation, and to doubts about transmission, transmission prevention, and on how to proceed in case of symptoms. PRACTICE IMPLICATIONS: These results may inform future communication strategies for a more adequate response in the next phases of the COVID-19 pandemic, as well as in future pandemics.

Urban Rail Transportation and SARS-Cov-2 Infections: An Ecological Study in the Lisbon Metropolitan Area.

Introduction: The large number of passengers, limited space and shared surfaces can transform public transportation into a hub of epidemic spread. This study was conducted to investigate whether proximity to railway stations, a proxy for utilization, was associated with higher rates of SARS-CoV-2 infection across small-areas of the Lisbon Metropolitan Area (Portugal). Methods: The number of SARS-CoV-2 confirmed infections from March 2 until July 5, 2020 at the parish-level was obtained from the National Epidemiological Surveillance System. A Geographic Information System was used to estimate proximity to railway stations of the six railway lines operating in the area. A quasi-Poisson generalized linear regression model was fitted to estimate the relative risks (RR) and corresponding 95% confidence intervals (95%CI). Results: Between May 2 and July 5, 2020, there were a total of 17,168 SARS-CoV-2 infections in the Lisbon Metropolitan Area, with wide disparities between parishes. Overall, parishes near any of the railway stations of the Sintra line presented significantly higher SARS-CoV-2 infection rates (RR = 1.42, 95%CI 1.16, 1.75) compared to parishes located farther away from railway stations, while the opposite was observed for parishes near other railway stations (Sado and Fertagus lines), where infection rates were significantly lower than those observed in parishes located farther away from railway stations (RR = 0.66, 95%CI 0.50, 0.87). The associations varied according to the stage of the epidemic and to the mitigation measures enforced. Regression results also revealed an increasing influence of socioeconomic deprivation on SARS-CoV-2 infections. Conclusions: No consistent association between proximity to railway stations and SARS-CoV-2 infection rates in the most affected metropolitan area of Portugal was observed, suggesting that other factors (e.g., socioeconomic deprivation) may play a more prominent role in the epidemic dynamics.

A Case-Control Study of Contextual Factors for SARS-CoV-2 Transmission.

Background: Knowledge on the settings and activities associated with a higher risk of SARS-CoV-2 transmission is essential to inform decision-making. We thus designed a case-control study to identify relevant settings for community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Portugal. Methods: We evaluated 1,088 cases, identified through the national surveillance system, and 787 community controls, recruited using random digit dialing. Sociodemographic characteristics, individual protective measures, and activities or visited settings were obtained through telephone interview. We report sex-, age-, education-, and citizenship-adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). Results: Household overcrowding (aOR = 1.47; 95% CI 1.14-1.91) and work in senior care (4.99; 1.30-33.08) increased while working remotely decreased the risk of infection (0.30; 0.22-0.42). Going to restaurants/other dining spaces (0.73; 0.59-0.91), grocery stores (0.44; 0.34-0.57) or hair salons (0.51; 0.39-0.66), or the use of public transportation did not present a higher risk of infection (0.98; 0.75-1.29), under existing mitigation strategies. Lower education ( ≤ 4 years vs. tertiary education: 1.79; 1.33-2.42) and no Portuguese citizenship (5.47; 3.43-9.22) were important risk factors. Conclusions: The utilization of public transportation, restaurants, and commercial spaces was not associated with increased risk of infection, under capacity restrictions, physical distancing, use of masks, and hygiene measures. Overcrowding, foreign citizenship, low education and working on-site were positively associated with SARS-CoV-2 infection.