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

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

Monitoring COVID-19 and Influenza: The Added Value of a Severe Acute Respiratory Infection Surveillance System in Portugal.

Background: Severe acute respiratory infections (SARI) surveillance is recommended to assess the severity of respiratory infections disease. In 2021, the National Institute of Health Doutor Ricardo Jorge, in collaboration with two general hospitals, implemented a SARI sentinel surveillance system based on electronic health registries. We describe its application in the 2021/2022 season and compare the evolution of SARI cases with the COVID-19 and influenza activity in two regions of Portugal. Methods: The main outcome of interest was the weekly incidence of patients hospitalized due to SARI, reported within the surveillance system. SARI cases were defined as patients containing ICD-10 codes for influenza-like illness, cardiovascular diagnosis, respiratory diagnosis, and respiratory infection in their primary admission diagnosis. Independent variables included weekly COVID-19 and influenza incidence in the North and Lisbon and Tagus Valley regions. Pearson and cross-correlations between SARI cases, COVID-19 incidence and influenza incidence were estimated. Results: A high correlation between SARI cases or hospitalizations due to respiratory infection and COVID-19 incidence was obtained (ρ = 0.78 and ρ = 0.82, respectively). SARI cases detected the COVID-19 epidemic peak a week earlier. A weak correlation was observed between SARI and influenza cases (ρ = -0.20). However, if restricted to hospitalizations due to cardiovascular diagnosis, a moderate correlation was observed (ρ = 0.37). Moreover, hospitalizations due to cardiovascular diagnosis detected the increase of influenza epidemic activity a week earlier. Conclusion: In the 2021/2022 season, the Portuguese SARI sentinel surveillance system pilot was able to early detect the COVID-19 epidemic peak and the increase of influenza activity. Although cardiovascular manifestations associated with influenza infection are known, more seasons of surveillance are needed, to confirm the potential use of cardiovascular hospitalizations as an indicator of influenza activity.

Resurgence of Respiratory Syncytial Virus in Children: An Out-of-Season Epidemic in Portugal.

INTRODUCTION: An out-of-season increase in respiratory syncytial virus (RSV) incidence was observed in Portugal from June 2021 onwards, revealing a continuing surge in cases throughout 2021/2022 autumn/winter. We aimed to describe this out-of-season epidemic and define its epidemic period, by analysing RSV incidence from week 40 of 2020 (2020-W40) to week 18 of 2022 (2022-W18). MATERIAL AND METHODS: Surveillance data on weekly RSV laboratory confirmed cases, in Portugal, was used to monitor RSV incidence using CUSUM test methodology for count data. RESULTS: In 2021-W23, the CUSUM score identified a significant increase in the risk of RSV. By that time, the percentage of RSV positive tests rose from 1% in 2021-W22 (3/265) to 6% in 2021-W23 (18/298). Despite a sharp decrease in RSV incidence on 2021-W33 and on 2022-W02, the CUSUM score stayed over the limit up to 2022-W07, indicating that the RSV activity remained at an epidemic level. Distinct peaks of RSV cases were observed between 2021-W30 and 2021-W32 (average of 77 RSV cases per week) and between 2021-W39 and 2021-W41 (average of 79 RSV cases per week) with positivity rates around 60%. CONCLUSION: An out-of-season RSV epidemic was identified, with a longer epidemic period compared with previous seasons. Possible reasons include relaxation of COVID-19 physical distancing measures and a greater proportion of population susceptible to disease. As several factors may change the pattern of RSV activity, countries should implement year-round surveillance RSV surveillance systems. These findings might have an impact on public health planning regarding future RSV surges, namely, on the palivizumab prophylaxis period for high-risk infants.

SARS-CoV-2 seroprevalence in Portugal following the third epidemic wave: results of the second National Serological Survey (ISN2COVID-19).

BACKGROUND: Integrated approaches to surveillance of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection are important for public health actions. The 2nd National Serological Survey (ISN2COVID-19) aimed to characterize the extent of SARS-CoV-2 infection and vaccine-induced response in the Portuguese population following the third epidemic wave and the launch of the vaccination campaign. METHODS: A cross-sectional study was performed using data on 8463 Portuguese 1-79 years of age, collected in February and March, 2021. SARS-CoV-2 IgM and IgG (anti-nucleoprotein and anti-spike) antibodies were determined in serum samples using Abbott Architect chemiluminescent microparticle assays. Post-infection and vaccine-induced seroprevalence with 95% confidence intervals (95%CI) were estimated in the overall sample and stratified by population characteristics. RESULTS: The estimated seroprevalence was 15.5% (95%CI:14.6-16.5%), of which 13.5% (95%CI: 12.6-14.4%) was attributable to natural infection and 2.0% (95%CI:1.7-2.4%) to vaccination. The lowest seroprevelence was observed in persons aged 70-79 years (8.9% 95%CI:6.8-11.6), while seroprevalence in children (14.3%; 95%CI:11.5-17.6%) and adolescents (12.9%; 95%CI:10.5-15.7%) was similar to that of persons aged between 20 and 69 years. Of seropositive individuals, 22.6% (95%CI:19.7-25.9%) did not report any symptoms in 6 months prior to interview. Of persons with completed vaccination (2-doses), 98.6% (95%CI: 93.0-99.7%) had specific IgG (anti-S) antibodies. CONCLUSIONS: After the third epidemic wave, the post-infection SARS-CoV-2 seroprevalence was 1.7 times higher than the cumulative incidence based on PCR-testing, but was higher (2.7 times) in children may be due to the high proportion of asymptomatic and mild infections.

Use of the NucliSENS EasyQ HPV assay in the management of cervical intraepithelial neoplasia.

Persistent infection by high-risk human papillomavirus is a necessary cause for cervical cancer. DNA-based human papillomavirus (HPV) assays show high sensitivity but poor specificity in detecting high-grade cervical lesions. Assays detecting mRNA of the oncoproteins E6 and E7 show higher specificity but lack either detection of all high-risk genotypes or the ability to specify the detected genotypes. The aim of this study was to evaluate the clinical performance of the NucliSENS EasyQ HPV assay in comparison with the Hybrid Capture 2 test (HC2) and the CLART Human Papillomavirus 2 assay (CLART), using a clinical cut-off of cervical intraepithelial neoplasia grade 2 or worse. In the 554 studied women, the lowest HPV positivity rate was detected for NucliSENS EasyQ HPV assay (55.1%), while HC2 and CLART showed similar results (HC2: 77.4%; CLART: 78.0%). In comparison with the other tests, the NucliSENS EasyQ HPV assay showed a lower clinical sensitivity (79.3% vs. 96.4% for HC2 and 95.9% for CLART) but a higher clinical specificity (72.6% vs. 42.8% for HC2 and 42.5% for CLART). Detection of E6/E7 mRNA transcripts may provide a higher specificity for cervical intraepithelial neoplasia grade 2 lesions or worse, since the oncogenic potential of HPV infection depends on the over-expression of these two oncoproteins.

[Biomarkers of cervical carcinogenesis associated with genital human papillomavirus infection]. / Indicadores de Prognóstico da Carcinogénese do Colo do Útero Associada à Infeção por Vírus do Papiloma Humano.

INTRODUCTION/OBJECTIVE: Persistent infection with high-risk human papillomavirus (HPV) types is a necessary cause for cervical cancer development. The aim of this study was to evaluate the significance of different molecular markers for cervical carcinogenesis, and to assess their association with cervical intraepithelial neoplasia. MATERIALS AND METHODS: 378 cervical samples from women attending to primary Health Clinics of the National Health Service and Gynaecological Outpatient Clinics and referred for HPV testing were analyzed between between January 2007 and December 2010. According to cytological diagnosis, five groups were defined: normal, ASCUS, LSIL, HSIL, and ICC. For the determination of viral DNA physical status was performed by using a real-time PCR methodology, over expression of E6/E7 mRNA NASBA amplification was performed with the NucliSENS EasyQ HPV assay and viral load was determined by a real-time PCR. HPV status was studied in relation to lesion severity. Statistical analysis was performed with SPSS software 16.0 and Chi-Square test. RESULTS: No significant statistical differences were found between the physical status of HPV 16 or 18 and lesion severity. Overexpression of E6/E7 mRNA increased with lesion severity. Viral load was significantly associated with the development of cervical intraepithelial lesion. CONCLUSIONS: Data suggests that viral integration for HPV 16 seems to be an early event on cervical carcinogenesis, not being suitable as a molecular marker. E6/E7 mRNA and viral load can be more valuable approaches to use as biomarkers in the prevention of cervical cancer development.

Introdução/Objetivos: A infeção persistente pelo Vírus do Papiloma Humano de alto risco (HPVar) é considerada como a causa necessária, embora não suficiente, para o desenvolvimento do cancro do colo do útero, sugerindo que outros fatores estarão envolvidos no processo de carcinogénese. Este estudo pretendeu avaliar indicadores de prognóstico da persistência da infeção por HPV, nomeadamente o estado físico e a carga viral dos HPV 16 e 18 e a superexpressão dos transcritos do RNAm dos HPV 16, 18, 31, 33 e 45, num grupo de mulheres com ou sem sintomatologia clínica e citopatológica. Material e Métodos: Foram estudadas 378 alíquotas de células epiteliais congeladas pertencentes a utentes dos centros de saúde do Serviço Nacional de Saúde e de clínicas privadas, referenciadas para teste HPV, entre Janeiro de 2007 e Dezembro de 2010. De acordo com o diagnóstico citopatológico, foram definidos cinco grupos: normal, ASCUS, LSIL, HSIL e carcinoma invasivo do colo do útero. Para a determinação do estado físico do DNA e da carga viral dos HPV 16 e 18 foi utilizada metodologia de PCR em tempo real, e para a superexpressão dos transcritos dos oncogenes E6 e E7 o sistema comercial NucliSENS EasyQ HPV®. Os indicadores foram analisados em associação com os tipos de lesão do colo do útero. Para a análise estatística foi utilizado o o programa informático SPSS versão 16.0 e o teste de Chi-Quadrado. Resultados: Os resultados mostraram ausência de associação estatisticamente significativa entre a gravidade da lesão e o estado físico do DNA dos HPV 16 e 18. A superexpressão dos transcritos do RNAm E6/E7 e a carga viral dos HPV 16 e 18 aumentaram significativamente em função do grau da lesão. Conclusões: Os resultados obtidos sugerem que a determinação do estado físico do DNA dos HPV 16 e 18, isoladamente, não constitui um indicador de prognóstico para o desenvolvimento e progressão das lesões. A superexpressão dos transcritos dos oncogenes E6 e E7 está associada à progressão das lesões do colo do útero e apresenta maior especificidade no diagnóstico precoce das lesões pré-malignas. A quantificação do DNA dos HPVar pode ser um indicador promissor de prognóstico das lesões pré-neoplásicas do colo do útero.

Clinical performance of the CLART human papillomavirus 2 assay compared with the hybrid capture 2 test.

Persistent infection by high-risk human papillomavirus (HR-HPV) is a cause of cervical cancer. The use of HPV detection in cervical screening programs may improve the ability to identify women at risk of cervical cancer. Therefore, the development of appropriate methods for the detection of HR-HPV is essential. The aim of this study was to evaluate the clinical performance of the CLART Human Papillomavirus 2 assay (CLART) in comparison with the Hybrid Capture 2 test (HC2), using a clinical cut-off of cervical intraepithelial neoplasia grade 2 or worse. Discrepant results were analyzed further by the PapilloCheck HPV genotyping system. In the 425 studied women, HR-HPV positivity rates were similar by both tests (CLART-13 HR-HPV: 63.1%; CLART-17 HR-HPV: 64.7%; HC2: 64.5%). Agreement between CLART-13 HR-HPV (κ = 0.969; concordance level 98.6%), CLART-17 HR-HPV (κ = 0.974; concordance level 98.8%), and HC2 were very good. When 13 HR-HPV types were considered, the two tests showed a clinical sensitivity of 96% (95% CI: 92.6-97.9). The clinical specificity of CLART-13 HR-HPV was 73.6% (95% CI: 66.7-79.5) for cervical intraepithelial neoplasia grade 2 or worse, which was comparable to HC2 (71.4%; 95% CI: 64.3-77.5). When all 17 HR-HPV types were considered, CLART showed a clinical sensitivity of 96.9% (95% CI: 93.8-98.5) and a clinical specificity of 71.9% (95% CI: 64.9-78.0). In conclusion, the CLART assay is efficient, sensitive, reproducible, and has a similar performance to HC2 for cervical intraepithelial neoplasia grade 2 or worse. Furthermore, this assay has the advantage of detecting and genotyping 35 HPV types by a single test, which can provide additional information on the predictive value of infection with HR-HPV.

Molecular variants of human papillomavirus type 16 and 18 and risk for cervical neoplasia in Portugal.

Persistent high-risk human papillomavirus (HPV) infection is considered as the central cause of invasive cervical cancer. Specific HPV 16 and 18 sequence variations were associated with an increased risk for progression. The purpose of this study was to analyze intratypic variations of HPV 16 and 18 within the E6 gene, MY09/11 and LCR regions, and to evaluate the risk of these variants for cervical neoplasia among Portuguese women. Cervical samples from 187 HPV 16-positive and 41 HPV 18-positive women with normal epithelium, cervical intraepithelial neoplasia, or invasive cervical cancer were amplified by type-specific PCR, followed by sequence and phylogenetic analysis. Sixteen new HPV 16 and 18 patterns are described in this paper. European HPV 16 variants were the most frequent (74.3%), particularly Ep-T350 (44.4%), followed by African (16.1%), and Asian-American (9.6%). Non-European HPV 16 variants were more frequent in pre-invasive lesions than in normal tissue and low-grade lesions. However, when analyzed separately, only African variants were associated significantly with an increased risk for cervical cancer. For HPV 18, the AsAi variant showed a trend, which was not statistically significant to an enhanced oncogenicity. European variants seemed to be significantly associated with a lower risk for cervical cancer development. The distribution of HPV 16 and 18 variants was not related to age or race among women living in the same geographical region. Knowledge of variants will be important for risk determination as well as for designing primers or probes for HPV detection methods, and for appropriate cervical cancer prevention strategies.