Epidemiological and Clinical Aspects of Cutaneous and Mucosal Leishmaniases in Portugal: Retrospective Analysis of Cases Diagnosed in Public Hospitals and Reported in the Literature between 2010 and 2020.

Leishmania infantum, a zoonotic vector-born parasite, is endemic in the Mediterranean region, presenting mostly as visceral (VL), but also as cutaneous (CL) and mucosal leishmaniasis (ML). This study aimed to describe the epidemiological and clinical aspects of the CL and ML cases diagnosed in mainland Portugal between 2010 and 2020. Collaboration was requested from every hospital of the Portuguese National Health System. Cases were screened through a search of diagnostic discharge codes or positive laboratory results for Leishmania infection. Simultaneously, a comprehensive literature search was performed. Descriptive statistics and hypothesis testing were performed using IBM® SPSS® Statistics. A total of 43 CL and 7 ML cases were identified, with a predominance of autochthonous cases (86%). In CL, immunosuppressed individuals constituted a significant proportion of patients (48%), and in this group, disseminated CL (22%) and simultaneous VL (54%) were common. In autochthonous cases, lesions, mostly papules/nodules (62%), were frequently observed on the head (48%). The approach to treatment was very heterogeneous. ML cases were all autochthonous, were diagnosed primarily in older immunosuppressed individuals, and were generally treated with liposomal amphotericin B. The findings suggest a need for enhanced surveillance and reporting, clinical awareness, and diagnostic capacity of these forms of leishmaniasis to mitigate underdiagnosis and improve patient outcomes. A holistic One Health approach is advocated to address the multifaceted challenges posed by leishmaniases in Portugal and beyond.

Knowledge and practices regarding leishmaniasis in Portugal - Comparison between blood donors and health students/professionals.

Objective: To compare the current knowledge and practices regarding leishmaniasis among blood donors and health students and professionals, in Portugal. Material and methods: Data were collected through the application of two questionnaires (one online and one in paper) with similar questions in two distinct cross-sectional independent studies, each targeting one of the groups. Descriptive statistics and hypothesis testing were performed using IBM® SPSS® Statistics. Results: In total, 3763 blood donors, 254 students and 232 professionals were included in the comparative analysis. Over 95% of students and professionals, but only around 70% of blood donors had previously heard of leishmaniasis. Over 90% of participants in each group admitted leishmaniasis affected animals, but only in the professional group over 90% were aware of human leishmaniasis. Conclusions: Even though canine leishmaniasis is recognized by many blood donors and by most students and professionals, awareness of the disease in humans is less common, highlighting the importance of promoting an approach to this infection through a One Health lens.

Knowledge, perceptions and practices of health students and professionals regarding leishmaniasis in Portugal: a cross-sectional study.

BACKGROUND: Control of leishmaniasis in the Mediterranean Basin relies on the active contributions from researchers in the fields of animal, human and environmental health. The application of knowledge, perceptions and practices (KPP) questionnaires to health students and professionals in Europe could be fundamental to identify and explore gaps in KPP, highlighting the diversity of conceptions related to this disease between students and professionals active in (One) Health. The objective of this study was to characterize and compare the current knowledge, perceptions and practices regarding leishmaniasis among subgroups of students and health professionals in Portugal through the application of an online questionnaire. METHODS: A cross-sectional study targeted the population of health students and professionals in Portugal, including students in medicine, veterinary medicine and environmental health, physicians, veterinarians and environmental health technicians. Potential participants were approached by email via universities and professional societies and organizations and provided with the link to access the online questionnaire. Answers to the self-administered sociodemographic and KPP questionnaire were collected between July and December 2022. Individual KPP scores were calculated by summing grades defined for each question. Logistic regression models were used to search for potential associations, and the results were expressed at estimated crude and adjusted odds ratios with 95% confidence intervals. RESULTS: In total, 486 participants were included in this study: 254 students and 232 professionals. Overall, 75% of the participants reported having heard of both human and animal leishmaniasis, and > 80% reported hearing about the disease during their course work (although this was significantly lower among those in the field of environmental health). Around 90% of participants identified the pathogenic agent as a parasite, and an arthropod bite was identified as the main route of transmission by > 95%. Animal leishmaniasis was considered to be diagnosed in Portugal by 87% of participants and human leishmaniasis by only 69%. The main barriers pointed out by professionals to the control of leishmaniasis were: lack of knowledge in the general population, failures in the early diagnosis and treatment of diseased animals, absence/inefficacy of vector control programs and lack of knowledge in human health professionals. Median knowledge and perception scores were higher among professionals in the animal health field and higher in professionals than in students. Median practice scores were not significantly different between groups and subgroups. The multivariate analysis revealed that a longer period of study (for students) and having seen cases of leishmaniasis (for physicians) were associated with above-mentioned median knowledge score. CONCLUSIONS: Most health students and professionals are knowledgeable about the cause and transmission route of leishmaniasis. However, recognition of the disease as autochthonous in humans is less common, highlighting the importance of promoting an approach to this infection through a One-Health lens. A national structured plan to control leishmaniasis could overcome some of the barriers pointed out by professionals, namely by implementing systematic phlebotomine surveillance and integrated reporting of animal and human cases of disease.

Prevalence of asymptomatic Leishmania infection and knowledge, perceptions, and practices in blood donors in mainland Portugal.

BACKGROUND: Asymptomatic infection is the most common outcome of exposure to Leishmania parasites. In the Mediterranean region, where Leishmania infantum is endemic, studies on the prevalence of asymptomatic infection have often relied on serological testing in blood donors. In Spain, regional studies have shown seroprevalence in blood donors between 1 and 8%; in Portugal, values of 0 and 2% were suggested by two localized studies, in different populations. The purpose of this study was (i) to estimate the prevalence of asymptomatic Leishmania infection in blood donors in mainland Portugal, and (ii) to study the association between the detection of antibodies to Leishmania and sociodemographic factors, and also the knowledge, perceptions and practices (KPP) of the blood donors regarding leishmaniasis. METHODS: A cross-sectional study targeted the population of people who donated blood in mainland Portugal. Participants, distributed proportionally by municipality and aged between 18 and 65 years, were selected randomly in 347 blood collection points between February and June 2022, and completed a sociodemographic and a KPP questionnaire. Detection of anti-Leishmania antibodies in serum was performed using an ELISA commercial kit. Individual KPP scores were calculated by adding grades defined for each question. RESULTS: Globally, 201/3763 samples were positive. The estimated national true seroprevalence was 4.8% (95% CI 4.1-5.5%). The proportion of positive results was significantly different between NUTS (Nomenclature of Territorial Units for Statistics) regions. Models suggested that seropositivity was significantly higher in male sex, people older than 25 years, or residing in the Centro NUTS2 region, but not in dog owners nor people with lower KPP scores. Overall, 72.3% of participants had previously heard of leishmaniasis and, in multivariate analysis, a higher Knowledge score was associated with age 25-40 years, female sex, ownership of dogs, and higher education. CONCLUSIONS: Global estimated true seroprevalence (4.8%) was similar to previous regional studies in blood donors in neighboring Spain. Higher seroprevalence values in the NUTS2 Centro region were consistent with incidence data from humans and seroprevalence studies in dogs. On the other hand, the low values in the Alentejo and the high values in the northern subregions may be the result of geographical shifts in parasite circulation due to climate change and should prompt localized and integrated, vector, canine, and human research, following a One Health approach.

The estimated distribution of autochthonous leishmaniasis by Leishmania infantum in Europe in 2005-2020.

BACKGROUND: This study describes the spatial and temporal distribution between 2005 and 2020 of human and animal leishmaniasis by Leishmania infantum in European countries reporting autochthonous cases, and highlights potential activities to improve disease control. METHODOLOGY/PRINCIPAL FINDINGS: It was based on a review of the scientific literature and data reported by the World Health Organization (WHO), the World Organization for Animal Health (WOAH) and the Ministries of Health, including hospital discharges in some countries. Autochthonous infections were reported in the scientific literature from 22 countries, including 13 and 21 countries reporting human and animal infections, respectively. In contrast, only 17 countries reported autochthonous human leishmaniasis cases to the WHO and 8 countries animal infections to the WOAH. The number of WOAH reported cases were 4,203, comprising 4,183 canine cases and 20 cases in wildlife. Of 8,367 WHO reported human cases, 69% were visceral leishmaniasis cases-of which 94% were autochthonous-and 31% cutaneous leishmaniasis cases-of which 53% were imported and mostly in France. The resulting cumulative incidence per 100,000 population of visceral leishmaniasis between 2005-2020, was highest in Albania (2.15 cases), followed by Montenegro, Malta, Greece, Spain and North Macedonia (0.53-0.42), Italy (0.16), Portugal (0.09) and lower in other endemic countries (0.07-0.002). However, according to hospital discharges, the estimated human leishmaniasis incidence was 0.70 in Italy and visceral leishmaniasis incidences were 0.67 in Spain and 0.41 in Portugal. CONCLUSIONS/SIGNIFICANCE: Overall, there was no evidence of widespread increased incidence of autochthonous human leishmaniasis by L. infantum in European countries. Visceral leishmaniasis incidence followed a decreasing trend in Albania, Italy and Portugal, and peaked in Greece in 2013, 2014 and 2017, and in Spain in 2006-2007 and 2011-2013. Animal and human cutaneous leishmaniasis remain highly underreported. In humans, hospital discharge databases provide the most accurate information on visceral leishmaniasis and may be a valuable indirect source of information to identify hotspots of animal leishmaniasis. Integrated leishmaniasis surveillance and reporting following the One Health approach, needs to be enhanced in order to improve disease control.

The current epidemiology of leishmaniasis in Turkey, Azerbaijan and Georgia and implications for disease emergence in European countries.

Leishmania spp. are sand fly-borne protozoan parasites causing leishmaniasis in humans and animals. The aim of the study was to analyse the epidemiology of leishmaniasis in Turkey, Azerbaijan and Georgia from 2005 to 2020 and evaluate the associated risk for disease emergence in European countries. It is based on an analysis of WHO and OIE reported cases between 2005 and 2020, a review of scientific articles published in SCOPUS between 2009 and 2020 and a questionnaire survey to public health and veterinary authorities in these countries. Endemic Leishmania spp. include L. infantum in the three countries, L. major in Azerbaijan and Turkey and L. tropica and L. donovani in Turkey. Leishmaniasis is reported in humans, animals and sand flies and incidence is spatially and temporarily variable. In the southern Caucasus and particularly in Georgia, reported incidence of human visceral leishmaniasis by L. infantum remains high. However, whilst Georgia experienced a gradual decrease from >4.0 cases per 100,000 population in 2005-09 to 1.13 cases per 100,000 population in 2020, the period with highest incidence in Azerbaijan, which ranged between 0.40 and 0.61 cases per 100,000 population, was 2016-2019, and no cases have so far been reported for 2020. Visceral leishmaniasis in the Southern Caucasus affects mostly young children from deprived urban areas and its closely associated to canine leishmaniasis. Turkey reported cases of visceral leishmaniasis between 2005 and 2012 and in 2016 only, and incidence ranged between 0.02 and 0.05 per 100,000 population. In contrast, the reported annual incidence of cutaneous leishmaniasis in Turkey was much greater and peaked at 7.02 cases per 100,000 population in 2013, associated to imported cases from cutaneous leishmaniasis endemic Syria. Leishmaniasis by L. infantum in Azerbaijan and Georgia represents a regional public and animal health challenge that requires support to improve diagnosis, treatment and control. The unprecedented rise of cutaneous leishmaniasis and the spread of L. tropica and L. donovani in Turkey is an important risk factor for their emergence in Europe, especially in Mediterranean countries where competent vectors are widespread.

Tuberculosis contact investigation in African Portuguese-speaking countries at End TB Strategy era: a scoping review.

OBJECTIVES: The contact investigation of tuberculosis (TB) index case is one of the critical elements pointed by the WHO to reach the end of the TB epidemic. The scoping review aimed to map out the recommended and the adopted processes applied to active contact investigation of TB index case in African Portuguese-speaking countries (PALOP). DESIGN: Scoping review. DATA SOURCES: We searched B-on, Cochrane Library, PubMed, Web of Science, Scopus, WHOLIS, IRIS, OKR, each country's Ministry of Health websites, WHO, Global Fund, World Bank and bibliographic reference lists from February to May 2020. ELIGIBILITY CRITERIA: All available literature on TB contact investigation in each country part of PALOP (Angola, Cape Verde, Guinea-Bissau, Mozambique and Sao Tome and Principe) published from 1 January 2010 to 31 January2020. DATA EXTRACTION AND SYNTHESIS: A data-charting form was developed to extract data on documents' characteristics and variables pertinent to the TB contact investigation process. Before qualitative analysis, we thematically synthesised findings and converted them into appropriate text units. RESULTS: Fifteen documents were included in the scoping review. The recommended processes for TB contact investigation were identified only for Cape Verde and Mozambique. It included clinical evaluation, counselling and testing for HIV, chest radiography, tuberculin skin test, sputum smear microscopy or Xpert MTB/RIF. The adopted processes were detected only in research studies from Angola, Guinea-Bissau and Mozambique. Therefore, they cannot be assumed as adopted within the scope of the national programmes of the respective countries. CONCLUSION: This review highlights the scarcity of references on TB contact investigation in PALOP at the End TB Strategy era. Furthermore, it is well clear the importance of an information system that provides actual data for assessing the real impact of such interventions in controlling the disease in African Portuguese-speaking countries.

Imported Malaria in Portugal: Prevalence of Polymorphisms in the Anti-Malarial Drug Resistance Genes pfmdr1 and pfk13.

Malaria is one of the 'big three' killer infectious diseases, alongside tuberculosis and HIV. In non-endemic areas, malaria may occur in travelers who have recently been to or visited endemic regions. The number of imported malaria cases in Portugal has increased in recent years, mostly due to the close relationship with the community of Portuguese language countries. Samples were collected from malaria-infected patients attending Centro Hospitalar Lisboa Ocidental (CHLO) or the outpatient clinic of Instituto de Higiene e Medicina Tropical (IHMT-NOVA) between March 2014 and May 2021. Molecular characterization of Plasmodium falciparum pfk13 and pfmdr1 genes was performed. We analyzed 232 imported malaria cases. The majority (68.53%) of the patients came from Angola and only three patients travelled to a non-African country; one to Brazil and two to Indonesia. P. falciparum was diagnosed in 81.47% of the cases, P. malariae in 7.33%, P. ovale 6.47% and 1.72% carried P. vivax. No mutations were detected in pfk13. Regarding pfmdr1, the wild-type haplotype (N86/Y184/D1246) was also the most prevalent (64.71%) and N86/184F/D1246 was detected in 26.47% of the cases. The typical imported malaria case was middle-aged male, traveling from Angola, infected with P. falciparum carrying wild type pfmdr1 and pfk13. Our study highlights the need for constant surveillance of malaria parasites imported into Portugal as an important pillar of public health.

Artemether-lumefantrine treatment failure of uncomplicated Plasmodium falciparum malaria in travellers coming from Angola and Mozambique.

The failure of artemisinin combination therapy (ACT) in malaria patients returning from endemic regions may be driven by parasite resistance to this treatment. ACT is used globally as the first-line treatment for Plasmodium falciparum malaria. However, artemisinin-resistant strains of P. falciparum have emerged and spread across Southeast Asia, with the risk of reaching high malaria burden regions in Africa and elsewhere. Here, we report on two malaria imported cases from Africa with possible parasite resistance to the ACT artemether-lumefantrine (AL). Case presentation: Two middle-aged males returning from Angola and Mozambique developed malaria symptoms in Portugal, where they were diagnosed and received treatment with AL as hospital inpatients. After apparent cure and discharge from hospital, these individuals returned to hospital showing signs of late clinical failure. Molecular analysis was performed across a number of drug resistance associated genes. No evidence of pfk13-mediated artemisinin resistance was found. Both subjects had complete parasite clearance after treatment with non-ACT antimalarials. Conclusion: Our case-studies highlights the need for close monitoring of signs of unsatisfactory antimalarial efficacy among AL treated patients and the possible implication of other genes or mutations in the parasite response to ACTs.

Leishmaniases in the European Union and Neighboring Countries.

A questionnaire survey of animal and human health authorities in Europe revealed that leishmaniases are not notifiable in all countries with autochthonous cases. Few countries implement surveillance and control targeting both animal and human infections. Leishmaniases are considered emergent diseases in most countries, and lack of resources is a challenge for control.

Health Problems During and After Travel: A Prospective Observational Study in a Travel Clinic in Portugal.

INTRODUCTION: In order to improve the health of travellers during travel it is important to better understand the health problems faced by travellers in different destinations. The main objective of this study was to characterise the perceived health problems of travellers during and up to six months after travel on a pre-travel clinic in Lisbon, Portugal. MATERIAL AND METHODS: This is a prospective observational study. Participants were recruited among those travellers attending a pretravel clinic between May 2016 and April 2017, meeting the inclusion criteria (age over 18 years old and predicted time of stay from five to 90 days). Structured questionnaires were applied by telephone interviews, three and six months after arrival. Associations and their magnitude were sought between travel and traveller's characteristics with total and specific health problems, using multiple logistic regression models. RESULTS: Out of 364 participants who completed the study, 60% were under 37 years of age, and 87.9% presented a higher educationaldegree. Africa and Asia were travel destinations for 89.1% of travellers. Three months after travel, 39.3% confirmed some travel-acquired health problem, namely diarrhoea (26.6%) and unmeasured fever (12.4%). A malaria case was diagnosed, occurring 3.5 months after return. From a total of 189 travellers to countries with high risk of malaria and chemoprophylaxis recommendation, 65.6% adhered completely and 6.9% of those presenting fever during travel sought healthcare. DISCUSSION: The proportion of travellers that became ill was lower compared to other published studies. Failure to follow a randomsampling method and the characteristics of the travel consultation with a particular profile of travellers in terms of level of education and ability to pay, challenges the external validity of the study. CONCLUSION: Health problems during or after travel occurred in 39.3% of travellers with diarrhoeal disease being the most common (26.6%). From our findings, the need for taking chemoprophylaxis for malaria or seeking health care in the presence of fever is not translated into appropriate action. The reasons are unclear and should be the subject of further research. Furthermore, research is needed with inclusion of other centres practicing travel medicine in Portugal, both in the pre-travel setting and others, in order to better understand the health risks associated with Portuguese traveller's characteristics and destinations.

Introdução: De forma a melhorar a saúde dos viajantes é necessário compreender os principais problemas de saúde enfrentados em diferentes destinos. O principal objetivo deste estudo foi caracterizar os problemas de saúde relatados por pessoas que recorreram a uma consulta do viajante em Lisboa durante e até seis meses após a viagem. Material e Métodos: Este é um estudo observacional e prospetivo. Os participantes foram recrutados entre os viajantes que compareceram na consulta entre maio de 2016 e abril de 2017, de acordo com os critérios de inclusão (idade igual ou superior a 18 anos e o tempo previsto de permanência em viagem de cinco a 90 dias). Os questionários estruturados foram aplicados por entrevistas telefónicas, três e seis meses após a chegada. Usando vários modelos de regressão logística, foram procuradas associações entre as características das viagens e dos viajantes com os problemas de saúde totais e específicos, e determinada a sua relevância. Resultados: Dos 364 participantes que completaram o estudo, 60% tinham menos de 37 anos de idade e 87,9% tinham um curso superior. As regiões de África e da Ásia foram os destinos de viagem para 89,1% dos viajantes. Três meses após a viagem, 39,3% dos viajantes relataram algum problema de saúde nomeadamente diarreia (26,6%) e febre (12,4%). Foi diagnosticado um caso de malária 3,5 meses após o regresso. Num total de 189 viajantes para regiões com indicação para quimioprofilaxia de malária, 65,6% tiveram uma adesão completa e 6,9% procuraram cuidados de saúde, no caso de febre durante a viagem. Discussão: A proporção de viajantes que adoeceu foi menor do que noutros estudos publicados. O não cumprimento de um método de amostragem aleatória e as características desta consulta de viajante, que apresenta um perfil específico de viajantes em termos de nível de escolaridade e capacidade de pagamento, colocam em causa a validade externa do estudo. Conclusão: Os problemas de saúde, durante ou após a viagem, ocorreram em 39,3% dos viajantes, sendo que a diarreia é o problema mais frequente (26,6%). A não adesão a recomendações carece de melhor caracterização. É necessário realizar este tipo de estudo em viajantes que não vão a consultas de aconselhamento antes da viagem e noutros centros de medicina do viajante, de forma a melhor caracterizar os riscos de doença associados a diferentes características e destinos dos viajantes portugueses.

[Scientific Research Policy for Health in Portugal: II - Facts and Suggestions]. / Política de Investigação Científica para a Saúde em Portugal: II ­ Factos e Sugestões.

After more than 40 years of democracy and 30 years of European integration, Portugal has bridged the research gap it had previously. However, when compared to global and European research policies, Portugal still has a long way go regarding investment in research and development. Health Research in Portugal has been managed by the Fundação para a Ciência e Tecnologia and the National Health Institute Doctor Ricardo Jorge, and it has not been a political priority, emphasized by the absence of a national scientific research plan for health, resulting in a weak coordination of actors in the field. The strategic guidelines of the 2004 - 2010 National Health Plan are what comes closest to a health research policy, but these were not implemented by the institutions responsible for scientific research for the health sector. Trusting that adopting a strategy of incentives to stimulate health research is an added-value for the Portuguese health system, the authors present five strategic proposals for research in health in Portugal.

Tendo Portugal superado o atraso científico estrutural vivido até há cerca de três décadas, a análise desta matéria à luz das políticas de investigação definidas a nível global e europeu mostra que há ainda um longo caminho a percorrer quando se fala em investimento global em Investigação & Desenvolvimento. A investigação para a saúde em Portugal tem tido tutela partilhada entre a Fundação para a Ciência e Tecnologia e o Instituto Nacional de Saúde Doutor Ricardo Jorge, sendo que esta matéria não tem sido uma prioridade - a realidade demonstra a não existência de um plano de investigação científica para a saúde em Portugal, o qual possa pôr em franca articulação os diferentes atores intervenientes. As orientações estratégias do Plano Nacional de Saúde 2004 - 2010 são as que mais se aproximam de uma política de investigação para a saúde para Portugal sem que, no entanto, as questões então abordadas tenham sido desenvolvidas de uma forma abrangente ou, à posteriori, implementadas pelas instituições que têm responsabilidades sobre a investigação científica no setor da saúde. Na convicção de que adoptar uma estratégia de incentivo à investigação para a saúde consiste uma mais-valia para o sistema de saúde português, os autores propõem neste trabalho cinco sugestões estratégicas em matérias de investigação para a saúde em Portugal.

[Scientific Research Policy for Health in Portugal: I - European and National Environment]. / Política de Investigação Científica para a Saúde em Portugal: I - Enquadramento Europeu e Nacional.

The global debate on scientific research policy for human health has been led by World Health Organisation with important contributions from other stakeholders such as Council on Health Research for Development, the World Bank and the Global Forum for Health Research. Recently it has been dominated by the thematic agendas of major global financiers. There is a growing interest worldwide in making better use of the evidence resulting from scientific research in health, in the decision-making process regarding health policies, which is fraught with difficulties, as it is the case in Europe. After more than 40 years of democracy and 30 years of European integration, Portugal has bridged the research gap it had previously. However, when compared to global and European research policies, Portugal still has a long way to go regarding investment in research and development.

O debate global sobre a política de investigação científica para a saúde humana tem sido liderado pela Organização Mundial da Saúde com contribuições importantes de outros stakeholders como o Council on Health Research for Development, o Banco Mundial e o Fórum Global para Investigação em Saúde, dominado recentemente pelas agendas temáticas de grandes financiadores globais. Existe um crescente interesse mundial em fazer melhor uso da evidência resultante da investigação científica para saúde, nas tomadas de decisão relacionadas com a definição de políticas de saúde. Na Europa verifica-se porém a existência de uma complexidade inerente à interação entre a investigação e a tomada de decisão política. Após cerca de 40 anos de democracia e 30 anos de integração europeia, Portugal superou o atraso científico estrutural. Contudo, a análise desta matéria à luz das políticas de investigação definidas a nível global e europeu mostra que há ainda um longo caminho a percorrer quando se fala em investimento global em Investigação & Desenvolvimento.

Ebola impact on African health systems entails a quest for more international and local resilience: the case of African Portuguese speaking countries.

INTRODUCTION: Ebola epidemics have shown to have significant impacts on many aspects of healthcare systems. African countries have been facing many difficulties while addressing Ebola epidemics, moreover due to both lack of resources and fragmented involvement of national and international entities. The participation of multiple organizations has created serious problems of coordination of aid and the operation of that aid on the ground. This paper aims at addressing the impact of Ebola epidemics on African health systems, with a special focus on the definition of impact mitigation guidelines and the role of resilience. The example of Portuguese speaking countries is presented. METHODS: A combination of literature review and case study methods are used. A literature review on Ebola outbreak impact on health systems will provide information to define a set of guidelines for healthcare services response to Ebola. The role of cooperation in providing additional resilience is described. Finally a case study focusing on the Portuguese collaboration and intervention in African Portuguese Speaking Countries (PALOP) is presented, as an example how the international community can provide additional resilience. RESULTS: The existing knowledge is very helpful to guide both the preparation and the coordination of Ebola preparedness interventions. Additional resilience can be provided by international cooperation. CONCLUSION: In addition to international concrete support in times of crisis, to have a regional strategy of creating (multi-national) teams to rapidly implement an intervention while establishing better regional capacity to have sufficient resources to support the "resilience" required of the health system.

Angola's 2013 dengue outbreak: clinical, laboratory and molecular analyses of cases from four Portuguese institutions.

INTRODUCTION: Dengue virus (DENV) is the arbovirus with the widest impact on human health. In Africa in general, and in Angola in particular, the epidemiology and public health impact of DENV is far from clear. However, rapid population growth, unplanned urbanization, increased international travel, and the presence of virus major vector (Aedes aegypti) in the country suggest that DENV transmission may occur. METHODOLOGY: In parallel to the occurrence of a dengue outbreak affecting the capital of Angola, between March and July 2013 four Portuguese institutions diagnosed dengue infection in 146 individuals returning to Portugal. Clinical presentation, laboratory findings, and molecular analyses of partial viral genomic segments were performed. RESULTS: The mean age of the individuals included in this study was 42 years old, the majority being men of Portuguese nationality, reporting various lengths of stay in Angola. Fever was the most reported clinical sign, being frequently associated (61.0%) with myalgia and headache. Hematological values, including hematocrit, white-blood cell and platelets counts, correlated with the absence of severe or complicated cases, or coagulation disorders. No deaths were observed. Viral NS1 was detected in 56.2% of the samples, and all NS1 negative cases had anti-dengue IgM antibodies. RT-PCR indicated the presence of DENV1, which was confirmed by phylogenetic analysis of 25 partial NS5 viral sequences. CONCLUSION: The DENV cases analyzed conformed to classical and uncomplicated dengue, caused by the suggested exclusive circulation of a genetically homogeneous DENV1 of genotype III, apparently with a single origin.

Health professionals moving to... and from Portugal.

The mobility of health professionals in the European Union is a phenomenon which policy-makers must take into account to provide the conditions to adjust for demand and supply of health services. This paper presents the case of Portugal, a country which at the same time imports and exports health workers. Since the early 1990s Portugal became a destination country receiving foreign health care professionals. This situation is now changing with the current economic situation as fewer immigrants come and more Portuguese emigrate. Foreigners coming to Portugal do so in part for similar reasons that bring Portuguese to want to emigrate, mainly the search for better work conditions and professional development opportunities. The emigration of Portuguese health professionals is also stimulated by the difficulty for recently graduated nurses, dentists and diagnostic and therapeutic technicians to find employment, low salaries in the public and private sectors, heavy workloads, remuneration not related to performance and poor career prospects. The paradoxes described in this study illustrate the consequences of the absence of a policy for the health professions. Strategies based on evidence, and on an integrated information system that captures the dynamic evolution of the workforce in health are not only necessary but also a good investment.

PHIRE (Public Health Innovation and Research in Europe): methods, structures and evaluation.

INTRODUCTION: Public Health Innovation and Research in Europe (PHIRE), building on previous European collaborative projects, was developed to assess national uptake and impacts of European public health innovations, to describe national public health research programmes, strategies and structures and to develop participation of researchers through the organizational structures of the European Public Health Association (EUPHA). This article describes the methods used. METHODS: PHIRE was led by EUPHA with seven partner organisations over 30 months. It was conceived to engage the organisation of EUPHA--working through its thematic Sections, and through its national public health associations--and assess innovation and research across 30 European countries. Public health research was defined broadly as health research at population and organisational level. There were seven Work Packages (three covering coordination and four for technical aspects) led by partners and coordinated through management meetings. RESULTS: Seven EUPHA Sections identified eight innovations within the projects funded by the Public Health Programme of the European Commission Directorate for Health and Consumers. Country informants, identified through EUPHA thematic Sections, reported on national uptake of the innovations in eight public health projects supported by the European Union Public Health Programme. Four PHIRE partners, each taking a regional sector of Europe, worked with the public health associations and other informants to describe public health research programmes, calls and systems. A classification was created for the national public health research programmes and calls in 2010. The internal and external evaluations were supportive. CONCLUSIONS: PHIRE described public health innovations and research across Europe through national experts. More work is needed to conceptualize and define public health 'innovations' and to develop theories and methods for the assessment of their uptake and impacts at country and cross-country levels. More attention to methods to describe and assess national public health research programmes, strategies and structures--contributing to development of the European Research Area.

Civil society engagement in innovation and research through the European Public Health Association.

BACKGROUND: The European Public Health Association (EUPHA) proposed and led PHIRE (Public Health Innovation and Research in Europe), with co-financing by the European Commission, to assess public health innovation and research at national level in Europe. PHIRE was also designed to promote organizational development and capacity building of EUPHA. We assess the success and limitations of using EUPHA's participative structures. METHODS: In total, 30 European countries were included-27 EU countries, Iceland, Norway and Switzerland. EUPHA thematic section presidents were asked to identify country informants to report, through a web-based questionnaire, on eight public health innovations. National public health associations (EUPHA member organizations) were requested to identify their national public health research programmes and calls, review the health research system, coordinate a stakeholder workshop and provide a national report. The section and national reports were assessed for responses and completeness. RESULTS: Half of the final responding CIs were members of EUPHA sections and the other half gained from other sources. Experts declined to respond for reasons including lack of time, knowledge of the innovation or funding. National public health associations held PHIRE workshops with Ministries of Health in 14 countries; information for 10 countries was gained through discussions within the national association, or country visits by PHIRE partners. Six countries provided no response. Some national associations had too weak organizational structures for the work or insufficient financial resources or criticism of the project. CONCLUSION: EUPHA is the leading civil society organization giving support to public health research in Europe. PHIRE created new knowledge and supported organizational development. EUPHA sections gained expert reports on public health innovations in European countries and national public health associations reported on national public health research systems. Significant advances could be made if the European Commission worked more directly with EUPHA's expert members and with the national public health associations.