Is a tiered restrictions system an effective intervention for COVID-19 control? Results from Portugal, November-December 2020.

BACKGROUND: In November 2020, similar to other European countries, Portugal implemented a tiered restrictions system to control the COVID-19 pandemic. We aimed to compare the COVID-19 growth rate across tiers to assess the effect of a tiered restrictions system in Portugal, using models with different times between tiers assessment. Our hypothesis was that being in a higher tier brings a faster deceleration in the growth rate than being in a lower tier. METHODS: The national database of notified COVID-19 cases and publicly available data were used to analyse the effect of the tiered restrictions system on the COVID-19 incidence growth rate. The tiers were based on the European Centre for Disease Control risk classification: moderate, high, very and extremely high. We used a generalised mixed-effects regression model to estimate the growth rate ratio (GRR) for each tier, comparing the growth rates of higher tiers using moderate tier as reference. Three models were fitted using different times between tiers assessment, separated by 14 days. RESULTS: We included 156 034 cases. Very high tier was the most frequent combination in all the three moments assessed (21.2%), and almost 50% of the municipalities never changed tier during the study period. Immediately after the tiers implementation, a reduction was identified in the municipalities in high tier (GRR high tier: 0.90 [95%CI: 0.79; 1.02]) and very high tier (GRR very high tier: 0.68 [95%CI: 0.61; 0.77]), however with some imprecision in the 95% confidence interval for the high tier. A reduction in very high tier growth rate was identified two weeks (GRR: 0.79 [95%CI: 0.71; 0.88]) and four weeks (GRR: 0.77 [95%CI: 0.74; 0.82]) after the implementation, compared to moderate tier. In high tier, a reduction was also identified in both times, although smaller. CONCLUSIONS: We observed a reduction in the growth rate in very high tier after the tiered restriction system was implemented, but we also observed a lag between tiered restriction system implementation and the onset of consequent effects. This could suggest the importance of early implementation of stricter measures for pandemic control. Thus, studies analysing a broader period of time are needed.

Association between area-level walkability and glycated haemoglobin: a Portuguese population-based study.

Diabetes poses a substantial disease burden, prompting preventive interventions. Physical inactivity, a major risk factor for type 2 diabetes, can potentially be mitigated by enhancing area-level walkability. Despite this, limited population-based studies have investigated the link between walkability and objective diabetes measures. Our study aims to estimate the association between area-level walkability and individual glycated haemoglobin levels in the Portuguese adult population without the diagnosis of diabetes. Data from the 2011 census and an updated street map were obtained to construct a walkability index based on residential density, land-use mix, and street connectivity. Individual health data were sourced from The National Health Examination Survey (INSEF) 2015, a representative survey of the Portuguese adult population. Gamma regression was employed for estimation of the main associations, revealing that residing in moderately walkable areas significantly reduced average glycated haemoglobin levels (Exp(ß) = 0.906; 95% CI: 0.821, 0.999) compared to the least walkable areas. The association was less pronounced and not statistically significant for the third tertile of walkability (Exp(ß) = 0.919; 95% CI: 0.822, 1.028). Our findings highlight a nonlinear protective association between walkability and glycated haemoglobin, emphasizing the potential policy implications for urban planning, diabetes prevention, and health promotion.

Relative vaccine effectiveness against COVID-19 hospitalisation in persons aged ≥ 65 years: results from a VEBIS network, Europe, October 2021 to July 2023.

To monitor relative vaccine effectiveness (rVE) against COVID-19-related hospitalisation of the first, second and third COVID-19 booster (vs complete primary vaccination), we performed monthly Cox regression models using retrospective cohorts constructed from electronic health registries in eight European countries, October 2021-July 2023. Within 12 weeks of administration, each booster showed high rVE (≥ 70% for second and third boosters). However, as of July 2023, most of the relative benefit has waned, particularly in persons ≥ 80-years-old, while some protection remained in 65-79-year-olds.

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.

Comparative Effectiveness of Coronavirus Vaccine in Preventing Breakthrough Infections among Vaccinated Persons Infected with Delta and Alpha Variants.

We developed a case-case study to compare mRNA vaccine effectiveness against Delta versus Alpha coronavirus variants. We used data on 2,097 case-patients with PCR-positive severe acute respiratory syndrome coronavirus 2 infections reported in Portugal during May-July 2021. We estimated the odds of vaccine breakthrough infection in Delta-infected versus Alpha-infected patients by using conditional logistic regression adjusted for age group and sex and matched by the week of diagnosis. We compared reverse-transcription PCR cycle threshold values by vaccination status and variant as an indirect measure of viral load. We found significantly higher odds of vaccine breakthrough infection in Delta-infected patients than in Alpha-infected patients (odds ratio 1.96 [95% CI 1.22-3.14]), suggesting lower effectiveness of the mRNA vaccines in preventing infection with the Delta variant. We estimated lower mean cycle threshold values for the Delta cases (mean difference -2.10 [95% CI -2.74 to -1.47]), suggesting higher infectiousness than the Alpha variant.

Ambient Particulate Air Pollution and Daily Mortality in 652 Cities.

BACKGROUND: The systematic evaluation of the results of time-series studies of air pollution is challenged by differences in model specification and publication bias. METHODS: We evaluated the associations of inhalable particulate matter (PM) with an aerodynamic diameter of 10 µm or less (PM10) and fine PM with an aerodynamic diameter of 2.5 µm or less (PM2.5) with daily all-cause, cardiovascular, and respiratory mortality across multiple countries or regions. Daily data on mortality and air pollution were collected from 652 cities in 24 countries or regions. We used overdispersed generalized additive models with random-effects meta-analysis to investigate the associations. Two-pollutant models were fitted to test the robustness of the associations. Concentration-response curves from each city were pooled to allow global estimates to be derived. RESULTS: On average, an increase of 10 µg per cubic meter in the 2-day moving average of PM10 concentration, which represents the average over the current and previous day, was associated with increases of 0.44% (95% confidence interval [CI], 0.39 to 0.50) in daily all-cause mortality, 0.36% (95% CI, 0.30 to 0.43) in daily cardiovascular mortality, and 0.47% (95% CI, 0.35 to 0.58) in daily respiratory mortality. The corresponding increases in daily mortality for the same change in PM2.5 concentration were 0.68% (95% CI, 0.59 to 0.77), 0.55% (95% CI, 0.45 to 0.66), and 0.74% (95% CI, 0.53 to 0.95). These associations remained significant after adjustment for gaseous pollutants. Associations were stronger in locations with lower annual mean PM concentrations and higher annual mean temperatures. The pooled concentration-response curves showed a consistent increase in daily mortality with increasing PM concentration, with steeper slopes at lower PM concentrations. CONCLUSIONS: Our data show independent associations between short-term exposure to PM10 and PM2.5 and daily all-cause, cardiovascular, and respiratory mortality in more than 600 cities across the globe. These data reinforce the evidence of a link between mortality and PM concentration established in regional and local studies. (Funded by the National Natural Science Foundation of China and others.).

Differential Mortality Risks Associated With PM2.5 Components: A Multi-Country, Multi-City Study.

BACKGROUND: The association between fine particulate matter (PM2.5) and mortality widely differs between as well as within countries. Differences in PM2.5 composition can play a role in modifying the effect estimates, but there is little evidence about which components have higher impacts on mortality. METHODS: We applied a 2-stage analysis on data collected from 210 locations in 16 countries. In the first stage, we estimated location-specific relative risks (RR) for mortality associated with daily total PM2.5 through time series regression analysis. We then pooled these estimates in a meta-regression model that included city-specific logratio-transformed proportions of seven PM2.5 components as well as meta-predictors derived from city-specific socio-economic and environmental indicators. RESULTS: We found associations between RR and several PM2.5 components. Increasing the ammonium (NH4+) proportion from 1% to 22%, while keeping a relative average proportion of other components, increased the RR from 1.0063 (95% confidence interval [95% CI] = 1.0030, 1.0097) to 1.0102 (95% CI = 1.0070, 1.0135). Conversely, an increase in nitrate (NO3-) from 1% to 71% resulted in a reduced RR, from 1.0100 (95% CI = 1.0067, 1.0133) to 1.0037 (95% CI = 0.9998, 1.0077). Differences in composition explained a substantial part of the heterogeneity in PM2.5 risk. CONCLUSIONS: These findings contribute to the identification of more hazardous emission sources. Further work is needed to understand the health impacts of PM2.5 components and sources given the overlapping sources and correlations among many components.

PM10 exposure interacts with abdominal obesity to increase blood triglycerides: a cross-sectional linkage study.

BACKGROUND: Blood lipids and glucose levels dysregulation represent potential mechanisms intermediating the adverse cardiovascular effects of ambient particulate matter (PM) exposure. This study aims to estimate the effect of long-term PM10 exposure on blood lipids and glucose levels and to assess the potential mediation and/or modification action of abdominal obesity (AO) (waist-to-height ratio). METHODS: Our study was based on 2,390 participants of the first Portuguese Health Examination Survey (INSEF, 2015) with available data on blood lipids and glucose parameters and living within a 30-km radius of an air quality monitoring station with available PM10 measurements. PM10 concentrations were acquired from the air quality monitoring network of the Portuguese Environment Agency. Generalized linear models were used to assess the effect of 1-year PM10 exposure on blood lipids and glucose levels. An interaction term was introduced in the models to test the modification action of AO. RESULTS: We found an association between PM10 and non-fasting blood triglycerides (TG) after adjustment for age, sex, education, occupation, lifestyles-related variables and temperature but only in participants with AO. Per each 1 µg/m3 PM10 increment, there was a 1.84% (95% confidence interval: 0.02-3.69) increase in TG. For the remaining blood lipid and glucose parameters, no associations were found. CONCLUSIONS: Our study demonstrates that even at low levels of exposure, long-term PM10 exposure interacts with AO to increase blood TG. Our findings suggest that reducing both AO prevalence and PM10 below current standards would result in additional health benefits for the population.

Impact of stringent non-pharmaceutical interventions applied during the second and third COVID-19 epidemic waves in Portugal, 9 November 2020 to 10 February 2021: an ecological study.

BackgroundNon-pharmaceutical interventions (NPIs) were implemented worldwide to control the spread of SARS-CoV-2.AimTo evaluate the impact of tiered NPIs and a nationwide lockdown on reduction of COVID-19 incidence during the second and third epidemic waves in Portugal.MethodsSurveillance data on laboratory-confirmed COVID-19 cases were used to conduct an interrupted time series analysis to estimate changes in daily incidence during a second wave tiered NPI period (9 November-18 December 2020), and a third wave lockdown period without (15-21 January 2021) and with school closure (22 January-10 February 2021).ResultsSignificant changes in trends were observed for the overall incidence rate; declining trends were observed for tiered NPIs (-1.9% per day; incidence rate ratio (IRR): 0.981; 95% confidence interval (CI): 0.973-0.989) and a lockdown period without (-3.4% per day; IRR: 0.966; 95% CI: 0.935-0.998) and with school closure (-10.3% per day, IRR: 0.897; 95% CI: 0.846-0.951). Absolute effects associated with tiered NPIs and a lockdown on a subsequent 14-day period yielded 137 cases and 437 cases per 100,000 population potentially averted, respectively.ConclusionOur results indicate that tiered NPIs implemented during the second wave caused a decline in COVID-19 incidence, although modest. Moreover, a third wave lockdown without school closure was effective in reducing COVID-19 incidence, but the addition of school closure provided the strongest effect. These findings emphasise the importance of early and assertive decision-making to control the pandemic.

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.

Estimation of COVID-19 vaccine effectiveness against hospitalisation in individuals aged ≥ 65 years using electronic health registries; a pilot study in four EU/EEA countries, October 2021 to March 2022.

By employing a common protocol and data from electronic health registries in Denmark, Navarre (Spain), Norway and Portugal, we estimated vaccine effectiveness (VE) against hospitalisation due to COVID-19 in individuals aged ≥ 65 years old, without previous documented infection, between October 2021 and March 2022. VE was higher in 65-79-year-olds compared with ≥ 80-year-olds and in those who received a booster compared with those who were primary vaccinated. VE remained high (ca 80%) between ≥ 12 and < 24 weeks after the first booster administration, and after Omicron became dominant.

Effects of Hot Nights on Mortality in Southern Europe.

BACKGROUND: There is strong evidence concerning the impact of heat stress on mortality, particularly from high temperatures. However, few studies to our knowledge emphasize the importance of hot nights, which may prevent necessary nocturnal rest. OBJECTIVES: In this study, we use hot-night duration and excess to predict daily cause-specific mortality in summer, using multiple cities across Southern Europe. METHODS: We fitted time series regression models to summer cause-specific mortality, including natural, respiratory, and cardiovascular causes, in 11 cities across four countries. We included a distributed lag nonlinear model with lags up to 7 days for hot night duration and excess adjusted by daily mean temperature. We summarized city-specific associations as overall-cumulative exposure-response curves at the country level using meta-analysis. RESULTS: We found positive but generally nonlinear associations between relative risk (RR) of cause-specific mortality and duration and excess of hot nights. RR of duration associated with nonaccidental mortality in Portugal was 1.29 (95% confidence interval [CI] = 1.07, 1.54); other associations were imprecise, but we also found positive city-specific estimates for Rome and Madrid. Risk of hot-night excess ranged from 1.12 (95% CI = 1.05, 1.20) for France to 1.37 (95% CI = 1.26, 1.48) for Portugal. Risk estimates for excess were consistently higher than for duration. CONCLUSIONS: This study provides new evidence that, over a wider range of locations, hot night indices are strongly associated with cause-specific deaths. Modeling the impact of thermal characteristics during summer nights on mortality could improve decisionmaking for preventive public health strategies.

Association between area- and individual-level socio-economic factors with glycated haemoglobin-Evidence from a Portuguese population-based study.

AIMS: This study aims to estimate the associations between area-level deprivation and individual-level socio-economic factors, as well as their interaction, with glycated haemoglobin (HbA1c ) levels. METHODS: We conducted a gamma multilevel regression analysis using individual-level data from the Portuguese National Health Examination Survey and a deprivation index built through factor analysis, at municipality level, with census variables. RESULTS: Living in a municipality with high material deprivation and having a low level of education were independently associated with an increase of 2.3% (95% confidence interval [CI] 0.6, 4.0) and of 1.6% (95% CI 0.6, 2.7) in the mean levels of HbA1c , respectively. The interaction between area material deprivation and individual-level education was not associated with the levels of HbA1c (0.5%, 95% CI -1.3, 2.3). CONCLUSIONS: Our findings support the collective resources model that argues that people in less deprived areas have better health because there are more collective resources. The results suggest that to reduce socio-economic inequalities associated with the levels of HbA1c and, consequently, with diabetes, will require attention to the area material deprivation and individual-level education. Upstream social determinants of health are thus highlighted.

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.

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.

Tracking SARS-CoV-2 lineage B.1.1.7 dissemination: insights from nationwide spike gene target failure (SGTF) and spike gene late detection (SGTL) data, Portugal, week 49 2020 to week 3 2021.

We show that the SARS-CoV-2 B.1.1.7 lineage is highly disseminated in Portugal, with the odds of B.1.1.7 proportion increasing at an estimated 89% (95% confidence interval: 83-95%) per week until week 3 2021. RT-PCR spike gene target late detection (SGTL) can constitute a useful surrogate to track B.1.1.7 spread, besides the spike gene target failure (SGTF) proxy. SGTL/SGTF samples were associated with statistically significant higher viral loads, but not with substantial shift in age distribution compared to non-SGTF/SGTL cases.

"Truly holistic?" Differences in documenting physical and psychosocial needs and hope in Portuguese palliative patients.

OBJECTIVE: Palliative care (PC) aims to improve patients' and families' quality of life through an approach that relieves physical, psychosocial, and spiritual suffering, although the latter continues to be under-assessed and under-treated. This study aimed to describe the prevalence of physical, psychosocial, and hope assessments documented by a PC team in the first PC consultation. METHOD: The retrospective descriptive analysis of all first PC consultations registered in our anonymized database (December 2018-January 2020), searching for written documentation regarding (1) Edmonton Symptom Assessment Scale (ESAS) physical subscale (pain, tiredness, nausea, drowsiness, appetite, shortness of breath, constipation, insomnia, and well-being), (2) the single question "Are you depressed?" (SQD), (3) the question "Do you feel anxious?" (SQA), (4) feeling a burden, (5) hope-related concerns, (6) the dignity question (DQ), and (7) will to live (WtL). RESULTS: Of the 174 total of patients anonymously registered in our database, 141 PC home patients were considered for analysis; 63% were male, average age was 70 years, the majority had malignancies (82%), with a mean performance status of 52%. Evidence of written documentation was (1) ESAS pain (96%), tiredness (89%), nausea (89%), drowsiness (79%), appetite (89%), shortness of breath (82%), constipation (74%), insomnia (72%), and well-being (52%); (2) the SQD (39%); (3) the SQA (11%); (4) burden (26%); (5) hope (11%); (6) the DQ (33%); and (7) WtL (33%).Significant differences were found between the frequencies of all documented items of the ESAS physical subscale (29%), and all documented psychosocial items (SQD + SQA + burden + DQ) (1%), hope (11%), and WtL (33%) (p = 0.0000; p = 0.0005; p = 0.0181, respectively). SIGNIFICANCE OF RESULTS: There were differences between documentation of psychosocial, hope, and physical assessments after the first PC consultation, with the latter being much more frequent. Further research using multicenter data is now required to help identify barriers in assessing and documenting non-physical domains of end-of-life experience.

Healthcare use in patients with multimorbidity.

BACKGROUND: The existence of multiple chronic conditions in the same patient is a public health problem increasingly recognized as relevant to health systems. Individuals with multimorbidity have additional health needs, which imply a heavy burden in healthcare use. It is estimated that between 70% and 80% of the total health expenditure is used with chronic conditions. Patients with multimorbidity are responsible for up to 75% of primary care appointments. These patients are also high hospital users, with up to 14.6 times more risk of hospitalization. METHODS: This study analyses the association between healthcare use and multimorbidity in the Portuguese population aged 25-74 years old. The association between socioeconomic variables and healthcare use was studied, based on data from the first Portuguese Health Examination Survey using a logistic regression model, stratified by sex and adjusted for socioeconomic confounding variables. RESULTS: In patients with multimorbidity, there was a greater use of primary healthcare consultations, medical or surgical specialist consultations and hospitalizations. An association was established between female, older age groups and lower educational levels, and increased healthcare use. When adjusted to socioeconomic variables, the likelihood of using healthcare services can be as high as 3.5 times, when compared to patients without chronic conditions. CONCLUSION: Our results show a greater healthcare use in multimorbidity patients, both in primary and hospital care. The availability of scientific evidence regarding the use of healthcare services by multimorbidity patients may support health policy changes, which could allow a more efficient management of these patients.

Heat-related mortality at the beginning of the twenty-first century in Rio de Janeiro, Brazil.

Temperature record-breaking events, such as the observed more intense, longer-lasting, and more frequent heat waves, pose a new global challenge to health sectors worldwide. These threats are of particular interest in low-income regions with limited investments in public health and a growing urban population, such as Brazil. Here, we apply a comprehensive interdisciplinary climate-health approach, including meteorological data and a daily mortality record from the Brazilian Health System from 2000 to 2015, covering 21 cities over the Metropolitan Region of Rio de Janeiro. The percentage of absolute mortality increase due to summer extreme temperatures is estimated using a negative binomial regression modeling approach and maximum/minimum temperature-derived indexes as covariates. Moreover, this study assesses the vulnerability to thermal stress for different age groups and both genders and thoroughly analyzes four extremely intense heat waves during 2010 and 2012 regarding their impacts on the population. Results showed that the highest absolute mortality values during heat-related events were linked to circulatory illnesses. However, the highest excess of mortality was related to diabetes, particularly for women within the elderly age groups. Moreover, results indicate that accumulated heat stress conditions during consecutive days preferentially preceded by persistent periods of moderate-temperature, lead to higher excess mortality rather than sporadic single hot days. This work may provide directions in human health policies related to extreme climate events in large tropical metropolitan areas from developing countries, contributing to altering the historically based purely reactive response.

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.