Dear Editor, Previous studies have identified risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) severe outcomes preferentially among hospitalized patients; therefore, they may have understated the denominator of such estimations [1, 2]. We aimed to determine pre-hospital risk factors and estimate individual probabilities of SARS-CoV2 severe outcomes among a nationwide cohort of cases of SARS-CoV2 infection, including those with and without hospitalization. This was a retrospective analysis from a nationwide prospective registry, including confirmed (nasal/pharynx swab real-time polymerase chain reaction) cases of SARS-CoV2 infection notified to the Directorate-General of Health from March 02 until April 21, 2020, in Portugal. Primary endpoint was a composite of ICU admission or all-cause mortality until April 21. Multivariable analysis was performed with logistic regression. Internal validation was performed with bootstrapping. Models' performance was studied with calibration plots, c-statistic, and Brier score [3, 4]. Significance level was α = 0.05. Informed consent was waived due to the use of anonymized data and the current state of public health emergency. Overall, 18,647 cases were included in our analyses, following exclusion of 1623 (8.0%) cases without hospital admission status and 23 (0.1%) cases without outcome status.

No abstract

In Europe, cases of chlamydia (CT), gonorrhoea (NG) and syphilis (TP) are rising and coinfections and reinfections are common. As there are limited data on factors associated with these events in Portugal, this study may be valuable to inform prevention strategies. We conducted an analytical cross-sectional study with all probable and confirmed cases of CT (including lymphogranuloma venereum), NG and TP notified in Portugal in the national system of epidemiological surveillance (SINAVE®) between January 1st, 2015 and December 31st, 2018. Descriptive and multivariable analyses were conducted and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated. Among 6506 cases in SINAVE®, 858 (13.2%) were coinfections and 204 (3.1%) were reinfections. Coinfections were found in 14.0% of males and 10.2% of females, while reinfections were present in 3.8% of males and 0.8% of females. In multivariable analysis, coinfections were positively associated with being younger than 26 (aOR 2.45, 95% CI 1.81-3.30), living in Lisbon area (aOR 1.43, 95% CI 1.13-1.81), being symptomatic (aOR 1.82, 95% CI 1.53-2.18), being men who have sex with men (MSM) (aOR 1.63, 95% CI 1.28-2.07), HIV+ status (aOR 1.46, 95% CI 1.19-1.80) and being diagnosed in an NGO (aOR 1.68, 95% CI 1.29-2.19). Reinfections were positively associated with living in Lisbon area (aOR 2.53, 95% CI 1.43-4.47), being symptomatic (aOR 2.37, 95% CI 1.66-3.37), being MSM (aOR 3.69, 95% CI 2.17-6.30) and HIV+ status (aOR 1.68, 95% CI 1.18-2.39). This study contributes to identifying risk profiles for coinfection and reinfection by these STIs in Portugal. Younger age, living in Lisbon area, being MSM, HIV+ status and being diagnosed in an NGO are some of the associated factors. Targeted interventions are needed to tackle specific settings and populations to be successful in lowering STI's incidence in Portugal. Key messages We identified factors associated with coinfection and reinfection by chlamydia, gonorrhoea and syphilis in Portugal, that can be used to target interventions. A study to identify the changes and problems in sexual attitudes and sexual behaviour may be useful to help us understand this paradigm.

A measles outbreak has been occurring in a healthcare setting in Porto, Portugal, since early March 2018, posing public health challenges for a central hospital and the community. Up to 22 April, 96 cases were confirmed, 67 in vaccinated healthcare workers, mostly between 18-39 years old. Following identification of the first cases, control measures were rapidly implemented. Concomitantly, other measles cases were notified in the Northern Region of the country. No common epidemiological link was identified.

Background Socioeconomic differences have been observed in the risk of acquiring infectious diseases, but evidence regarding SARS-CoV-2 remains sparse. Hence, this study aimed to investigate the association between SARS-CoV-2 infection risk and socioeconomic deprivation, exploring whether this association varied according to different phases of the national pandemic response. Methods A cross-sectional study was conducted. Data routinely collected for patients with a laboratorial result recorded in SINAVE®, between 2 March and 14 June 2020, were analysed. Socioeconomic deprivation was assessed using quintiles of the European Deprivation Index (Q1-least deprived to Q5-most deprived). Response phases were defined as before, during and after the national State of Emergency. Associations were estimated using multilevel analyses. Results The study included 223 333 individuals (14.7% were SARS-CoV-2 positive cases). SARS-CoV-2 infection prevalence ratio increased with deprivation [PR(Q1)=Ref; PR(Q2)=1.37 (95% CI 1.19–1.58), PR(Q3)=1.48 (95% CI 1.26–1.73), PR(Q4)=1.73 (95% CI 1.47–2.04), PR(Q5)=2.24 (95% CI 1.83–2.75)]. This was observed during the State of Emergency [PR(Q5)=2.09 (95% CI 1.67–2.62)] and more pronounced after the State of Emergency [PR(Q5)= 3.43 (95% CI 2.66–4.44)]. Conclusion The effect of socioeconomic deprivation in the SARS-CoV-2 infection risk emerged after the implementation of the first State of Emergency in Portugal, and became more pronounced as social distancing policies eased. Decision-makers should consider these results when deliberating future mitigation measures.

COVID-19, although a respiratory illness, has been clinically associated with non-respiratory symptoms. We conducted a negative case–control study to identify the symptoms associated with SARS-CoV-2-positive results in Portugal. Twelve symptoms and signs included in the clinical notification of COVID-19 were selected as predictors, and the dependent variable was the RT-PCR test result. The χ2 tests were used to compare notified cases on sex, age group, health region and presence of comorbidities. The best-fit prediction model was selected using a backward stepwise method with an unconditional logistic regression. General and gastrointestinal symptoms were strongly associated with a positive test (P < 0.001). In this sense, the inclusion of general symptoms such as myalgia, headache and fatigue, as well as diarrhoea, together with actual clinical criteria for suspected cases, already updated and included in COVID-19 case definition, can lead to increased identification of cases and represent an effective strength for transmission control.

Background and objectives:COVID-19 related inflammation, endothelial dysfunction and coagulopathy may increase the bleeding risk and lower efficacy of revascularization treatments in patients with acute ischemic stroke. We aimed to evaluate the safety and outcomes of revascularization treatments in patients with acute ischemic stroke and COVID-19.Methods:Retrospective multicenter cohort study of consecutive patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021, tested for SARS-CoV-2 infection. With a doubly-robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT).Results:Of a total of 15128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19. 5848 (38.7%) patients received IVT-only, and 9280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted odds ratio [OR] 1.53; 95% CI 1.16–2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20–2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23–1.99), 24-hour (OR 2.47; 95% CI 1.58–3.86) and 3-month mortality (OR 1.88; 95% CI 1.52–2.33).COVID-19 patients also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26–1.60).Discussion:Patients with acute ischemic stroke and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 treated patients. Current available data does not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in COVID-19 patients, or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring and establishing prognosis.

Ethical considerations: Written informed consent was waived as this study was carried out for emerging infectious disease purposes and is part of a continuing public health outbreak investigation, under national authorisation of the Directorate-General of Health, entering in the epidemiological surveillance component.