“FUNI” Workshop

Thanks to our Italian members, EuroNet has been given the opportunity to organise a workshop at the Giornate degli Specializzandi in Igiene e Medicina Preventiva, which will take place on the 15th of June in the beautiful city of Catania.


Our president Alberto Mateo and E-RECT’s WG lead Špela Vidovič will lead the workshop, titled “FUNI” (Facilitating residents’ mobility, Undertaking research, Networking, Improving residency programmes). For one hour and a half, they will lead a discussion on how training programmes work across Europe; what the strengths and weaknesses of each programme are; how we can improve them and what EuroNet is already doing.
The workshop will be a fantastic opportunity to present and promote our network, as well as some of the work that we are doing, particularly in relation to the E-RECT study and the Professionalisation Working Group.
Our Italian members will be facilitating the workshop, making sure it is a success. They will also be in charge of showing the city to Alberto and Špela, as well as making sure they try some of the finest Sicilian food and wine. Pictures and report will follow the workshop. So, stay tuned!

Residency access in Italy: how did it change?

In Italy, procedures of application in medical residency have been deeply re-elaborated in the last four years. Until 2013, in order to pursue their own careers, young graduate doctors had to choose the University and the affiliated healthcare facility where they wanted to specialize, and take an entree exam there in these structures, through a local competition.

A first fundamental reform took place in 2014, when the introduction of a national competition replaced the hundreds of exams in the different Italian universities. Therefore, candidates were asked to individually choose up to six different branches of medicine, as well as to locate some preferred facilities; after the competition, the Ministry of Education, University and Research (MIUR) issued several national rankings, one for each medical specialization. The examination consisted of a multiple-choice test subdivided into a first general part identical for all, a second one based on three different macro-areas (medical area, surgical area, and area of health services), and a final ten-question test specific to different branches. In the following two years, residency access competitions remained almost unchanged.

Yet, the 2017 edition, albeit being structured along the lines of the previous ones, has been developed following a new regulation adopted by the MIUR on September 6th, with the purpose of streamlining and making the test procedures more transparent. Moreover, access to the different Schools of Specialization is now regulated by an annual national multiple-choice test. This test is the same for all students throughout the country, and it consists of 140 questions about key topics related to Medical School’s programmes, as well as some questions more specific to all the different medical branches.

A single national ranking including all the participants is then drafted based on the test’s scores. Starting from top of the list, each participant doctor who won a place as a resident is contacted in order to let him choose and declare both the preferred school of specialization and the selected city facilities. Each doctor is given the possibility of choosing up to three different kind of residencies, in order of preference. The achievement of high test scores allows to get a good ranking. The final score is calculated by summing the number of correct answers (that are worth 1 point each, while each wrong answer means losing 0.25 a point) to “extra-test” points, represented by University curriculum, which weighs definitely less than it used to in the previous tests ; in fact, now it is less than 7 points – rather than 15 – consisting of: up to 2 points for the degree grade, up to 3 points assigned after the weighted average of university exams’ grades, 0.5 a point per an experimental graduation thesis, and 1.5 points for a previous Ph.D.

Each annual edition of this new modality of residency access has to be specifically addressed by a competition notice published around the month of May.

In conclusion, this new national test was held last November, and, starting from December 4th, the awarded candidate doctors were able to choose the preferred available facilities, in a batch process depending on their score and rank position. The last residents’ allocation was held on December 22nd.

To those who have just started their training activities, all that remains for us to do is to wish you good luck, or if you prefer, buona fortuna!

More details at: MIUR, Italy – www.miur.gov.it

_________________________

Pietro Ferrara
Public Health Resident, University of Campania “L. Vanvitelli”, Naples, Italy

Viola Del Prete
Public Health Resident, University of Campania “L. Vanvitelli”, Naples, Italy

(As published in EuroNews #13)

Public Health Residency: Time for Focus and Opportunity

Last  January, I started my residency in Public Health in Oporto, at an institution responsible for all the population living or working in the oriental area of the city. I’m very pleased with my choice and I feel very welcomed by this big community. Fortunately, public health in Portugal is on the rise in the last 8 years with an increase number of all public health professionals. Even in Europe and all around the world, public health is becoming more prominent in order to have real impact in our lives and on the ones in most need. Euronet is an excellent example of the ambition and hard work of a new technological generation of public health doctors, understanding the value of a solid and robust network between different countries and cultures. One of my first goals, after choosing public health as my profession, was to find out what it is and its objectives. Besides its fundamental actions according to WHO, promoting health, preventing disease and prolonging life, and the additional ten major interventions that we can and should address on a daily basis, I read a sentence stated by Arnaldo Sampaio, a reference figure in the development of public health in Portugal, that, in my opinion, describes the range that public health can have, “If you want you can even consider the public lighting as a promoter of better Public Health, since it gives more safety to pedestrians and decreases the probability of road accidents”.

In the first residence year our program in Portugal is focused on community health. A major aim of this phase is to learn and practice epidemiological surveillance and intervention. In Oporto, we work with a population that has a big incidence of tuberculosis comparing with other regions of Portugal. It is characterized for having a low socioeconomic status and poor neighborhoods, and consequently low hygienic conditions and reduced search of healthcare treatment in due time, which are risk factors for acquiring the disease. Those conditions promote the spread of the disease between family, friends and work colleagues. Although our job’s aim is towards the identification of the source of the disease and all the contacts, there are, unfortunately, some barriers and bureaucratic restrictions that not allow us to do it properly. For example, the minimum 6 month period of treatment of tuberculosis is a huge downsize in the battle against the disease, since some cases doesn’t even complete the treatment, despite its mandatory order to do it under observation. One suggestion to fight those problems could be health institutions merely for treating tuberculosis where patients could be hospitalized during it, depending on the danger to themselves or others. We have the ability to, if not eradicate, reduce considerably the incidence of tuberculosis with new and good practices, using all the information that we have available today.

In almost two months I proudly declare that public health is exceeding my expectations, that I feel highly motivated and we all should encourage each other in order to overcome all the barriers that we might face along our path. Public health gives us all the tools to make a better, healthier and more sustainable world. Together, and perhaps with Euronet and its communication assets, we can make the difference.

_________________________

João Paulo Magalhães
MD, Public Health Resident, Portugal

(As published in EuroNews #13)

Public Health Masters in the context of Public Health Resident Training in Europe

Nowadays, large disparities are still present among the different Public Health Masters (MPH) included in the training programmes of public health residents in Spain. Moreover, the impending changes in our training programme may result in a reduction of specific public health training for public health residents from four to two years, with the likely exclusion of MPHs as part of these changes.(1)

The Spanish Association of Residents in Preventive Medicine and Public Health (ARES MPSP) is concerned about these discrepancies and their consequences within the European context. Our aim was to characterize the disparities present among the different public health resident training programmes across the European Countries. A survey was developed to this end.

All members present at the Strasbourg meeting, representing eight of the nine countries that are part of EuroNet-MPRH, participated at the survey, which consisted in a single question “Is MPH a compulsory course part of the residency programme?”. Ireland, the remaining country, received the survey via email.

All countries, except Italy and Ireland, declared to have a MPH programme as part of their residency training programme. In Ireland, MPH is optional (See figure 1). Regarding commitment and time-dedication, 33%(3/9) of the surveyed countries reported the presence of part-time MPHs, while 44% (4/9) reported full-time commitment programmes.

Figure 1

Fees are more often covered by the employer then students, except in France, where trainees must sustain the fees by themselves. In three countries costs are covered by the ministry.

All countries except Portugal and Slovenia have an official MPH title. Although Croatia has an official MPH title, they are unsure about the accreditation status. Schools in Portugal are encouraged to consider MPH programmes as the academic part of a master programme, where students pay an extra fee to present a thesis and to obtain a degree. Slovenia hopes to have one in the future (See figure 2).

The residents satisfaction with the training received during the MPH was assessed with the question “How satisfied are you with the training you have received?”. The results show a median satisfaction of 3.5 points out of 5 [IQR: 2-5] (See figure 3).  Moreover, residents were asked about what kind of changes they would like to observe inside the MPHs programmes (Table 1).

As presented, there are great disparities among different MPH programmes across Europe. It would be desirable to further unify MPH criteria in order to increase training quality and mobility.

_________________________

References

  1.  Inamo J. et al. Existe-t-il des spécificités dans la prévalence et la prise en charge de l’hypertension artérielle aux Antilles-Guyane par rapport à la France métropolitaine ? BEH thématique, 16 décembre 2008 ; 49-50. Romon I. et al. Le poids important du diabète sur la mortalité dans les départements d’outre-mer. InVS, Mars 2007.
  2. Jaries R. et al. Population movements and the HIV cascade in recently diagnosed patients at the French Guiana -Suriname border., 2017; 13:1-5
  3. Carde E. Les discriminations selon l’origine dans l’accès aux soins. Access to health care and racial discrimination. Santé publique 2007, volume 19, n° 2, pp. 99-109.

_________________________

Fátima C. Mori Gamarra
Preventive Medicine and Public Health resident at Complexo Hospitalario Universitario de Ourense, Galicia – Spain

Julio Muñoz Miguel
Preventive Medicine and Public Health resident at Hospital Clínico Malvarrosa, Valencia – Spain

Adrían Aginagalde Llorente
Preventive Medicine and Public Health resident at Hospital Universitario de Cruces – Spain

(As published in EuroNews #13)

French Guiana – Who is the stranger?

In France, as residents, we have the possibility to do a maximum of three rotations in a different place from the one where we are doing our residency. One lazy autumn evening I went through the list of the available rotations in French overseas departments, and I chose Saint-Laurent du Maroni, French Guiana. The choice was simple: a 37 years-old public health doctor had opened a whole public health department in Western French Guiana hospital 5 years before, just out of her residency, while getting a PhD with a thesis on migrants’ health. I could not ask for anything better.

French Guiana is a French overseas department, a former penal colony, wedged between Brazil and Suriname. It is a European outermost region and the only border of Europe with South American countries, it hosts a European spaceport from where Ariane rockets are launched every month and, of course, Euro is the currency.

I vaguely imagined what expected me. I read the data: the epidemiological profile of the region is similar to that of developing countries, where communicable diseases like dengue fever and leishmaniasis persist alongside a high prevalence of cardiovascular diseases and diabetes. HIV is epidemic (>1%), half of the population is less than 25 years old and the fertility rate is 3.5%.

The first thing I noticed when I arrived in Saint-Laurent, which has more than 40 thousands inhabitants and lies on the shore of the Maroni river, was the lack of public transportation. Being born and bred in cities, public transportation for me is a fundamental part of the landscape and the absence of it struck me immediately. Public transportation has practical implications, but also a symbolic meaning. It carries communities together and fights geographical isolation. In its absence, people living in the peripheries are left out of the public life. They cannot easily access services, which are historically aggregated in the city center. It did not take long to discover that isolation, lack of access to services, inequalities, structural discrimination would be key words of my experience here.

I participate in most of the activities of the public health department, whose mission spaces from prevention activities – an IST clinic, therapeutic patient education for chronic illnesses, cultural mediation, school interventions on sexual health… – to research and training, to international cooperation with neighboring Suriname, to providing medical missions to the health centers along the Maroni river. This allows me to have a glance at population needs and the difficulties to tackle them.

There is no single cause for the particular obstacles that may be encountered in health care in French Guiana. Part of the problem are practical issues: the scarcity of means – In terms of money but above all in terms of human resources – , the complexity of the territory – the road stops 50 km south of Saint-Laurent and you can only reach further towns by boat or by plane -, the distance from the capital city, where decisions are taken.  

However, it is not as straightforward as that. Working in this environment is the concrete exemplification of how determinants of health act.

Here, as professionals or laypeople, we are obliged to confront with theoretical and political questions that we do not usually think about in our day-to-day life, such as the subject of decentralization, the role and responsibilities of the State, the scars of colonialism, how societies form and develop. Questions arise about migrations and nationality3. We wonder who is a foreigner, is it the person who was born here but who does not speak French, is it the person who comes from across the river, is it the Parisian doctor, is it me, is it no one or are we all?

And the list of questions continues. How can we support sexual violence survivors, which can be count in hundreds every year? What is the best way to advocate for undocumented migrants and to provide appropriate services to mobile people? How do you tackle the complex ties between health, education, (lack of) job opportunities, social structures? What about indigenous population?

I do not have simple answers. However, I had the great opportunity to combine practice and reflection and to learn from dedicated professionals and for that I am grateful. I hope I leave you craving for more French Guiana.

_________________________

References

  1.  Inamo J. et al. Existe-t-il des spécificités dans la prévalence et la prise en charge de l’hypertension artérielle aux Antilles-Guyane par rapport à la France métropolitaine ? BEH thématique, 16 décembre 2008 ; 49-50. Romon I. et al. Le poids important du diabète sur la mortalité dans les départements d’outre-mer. InVS, Mars 2007.
  2. Jaries R. et al. Population movements and the HIV cascade in recently diagnosed patients at the French Guiana -Suriname border., 2017; 13:1-5
  3. Carde E. Les discriminations selon l’origine dans l’accès aux soins. Access to health care and racial discrimination. Santé publique 2007, volume 19, n° 2, pp. 99-109.

_________________________

Maria Francesca Manca
Public Health Resident, France

(As published in EuroNews #13)

Noncommunicable diseases in humanitarian settings

Women wheel their food rations, that have been donated by the Australian Governemnt, at a food distirbution point in Harare, Zimbabwe on the 23rd April, 2009.

In the 21st century, we live in a world regularly affected by emergencies, often with severe local and regional health consequences. In the context of climate change and corrosive political instability in many world regions, it is probable that we will see an increase in disasters or their resulting health impacts.1 By the end of 2016, 65.6 million people worldwide were forcibly displaced from their homes. The record number includes 22.5 million refugees, 2.8 million asylum seekers and 40.3 million people living in internal displacement (ID).2,3

The number of ID has nearly doubled since 2000 and has increased sharply over the last five years. For displaced populations health care has traditionally focused on maternal and child care and treatment of communicable diseases. While these traditional health priorities remain relevant, demographic and lifestyle changes are increasing the burden of noncommunicable diseases (NCD) in populations worldwide. This epidemiological shift poses new challenges for humanitarian agencies and host country governments. NCD accounted for 19% to 46% of mortality in the top 5 source countries for refugees in 2015.4

In the absence of regular care and access to medications, NCD may result in complications requiring costly specialised care and have the potential to seriously compromise both quality of life and life expectancy, since the risk of exacerbating pre-existing conditions or suffering acute complications, is two to three times higher than it was beforehand. In the initial response of an emergency management of NCDs should focus on treatment of life-threatening or severely symptomatic conditions. During the recovery phase after emergencies or during protracted emergencies such as long-term settlements, the management of NCDs should be expanded to include management of sub-acute and chronic presentations. WHO recognizes the growing problem of NCDs, and in 2013 introduced the Package of Essential Noncommunicable Disease Interventions, or WHO PEN, a set of tools to early detect and manage cardiovascular diseases, diabetes, chronic respiratory diseases and cancer in order to prevent life-threatening complications, such as myocardial infarction, stroke, kidney failure, amputations and blindness.5

There is a need to identify challenges and gaps in order to create a more holistic approach to effective planning, implementation and delivery of health care services to displaced populations with chronic NCD.

_________________________

References

  1. Demaio, A., Jamieson, J., Horn, R., de Courten, M., & Tellier, S. (2013). Non-Communicable Diseases in Emergencies: A Call to Action. PLoS Currents, 6, 5-23.
  2. UNHCR (2017). Global Trends – Forced Displacement in 2016. United Nations High Commissioner for Refugees, Geneva.
  3. IDMC (2017). Global Report on Internal Displacement. Internal Displacement Monitoring Centre, Geneva.
  4. Sethi, S., Jonsson, R., Skaff, R., & Tyler, F. (2017). Community-Based Noncommunicable Disease Care for Syrian Refugees in Lebanon. Global Health: Science and Practice, 5(3), 495–506.
  5. WHO (2010).Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-Resource Settings. World Health Organization, Geneva

_________________________

Ana Pinto de Oliveira
2nd year Public Health Resident
ACES Arco Ribeirinho, Barreiro, Portugal

Catarina Neves Oliveira
Public Health Specialist
ACES Arco Ribeirinho, Barreiro, Portugal

(As published in EuroNews #13)

Valencia Summer Meeting | Save The Date | 12-13 July 2018

 

It has become a habit of mine to pitch EuroNet MRPH whenever I am approached by future or new Public Health residents. This is very much how I was introduced to the organisation by a certain Mr Pantoja in the autumn of 2015. The idea isn’t hard to pitch: whether you’re interested in engaging in some international research collaboration or just plain old multicultural interaction and travel it’s an easy sell. Despite this it has always stricken me as odd how most residents that are initially interested in joining EuroNet never actually end up participating in any of the activities. How many Vinkos, Del Pretes or Scandalis have we lost to this lack of engagement? Although I can’t speak for everyone I can say that, for me, meetings were the real game changer. It’s one thing to hear the stories, to Skype with some faceless foreigners with internet connections of varying quality, and an entirely different one to exchange ideas over coffee or wine. To participate in a Melting Pot where fresh ideas from all over Europe are shared. Some say that you are the average of the people that you surround yourself with, and I can say that at some of these meetings is where I have felt at my best.

EuroNet meetings have definitely evolved over the past few years. From tiny mountain top towns to empire capitals. Taverns to town halls. Organizing a EuroNet meeting today means you have very big shoes to fill.

We are willing to accept that challenge.

The Spanish EuroNet and National Commission are happy to invite you to the 2018 EuroNet Summer Meeting in the city of Valencia, where we hope you will be inspired, motivated and perhaps even have a little fun.

 

Julio Muñoz
Spanish EuroNet Team

Valencia 2018
Come for the Paella. Stay for the Net.

Modern slavery

(Pixabay)

Modern slavery is the illegal trade of human beings for the purpose of commercial sexual exploitation or reproductive slavery, forced labour, or a modern-day form of slavery.

British and foreign nationals can be trafficked into, around and out of the UK. Children, women and men can all be victims of modern slavery. Reasons for trafficking of individuals include sexual exploitation, domestic servitude, forced labour including in the agricultural, construction, food processing, hospitality industries and in factories, criminal activity including cannabis cultivation, street crime, forced begging and benefit fraud, and organ harvesting. It distinguishes human trafficking as a crime against an individual, and smuggling as a crime against the state where there are illegal border crossings.

There are an estimated 13,000 modern slaves in the UK. To tackle modern slavery in the UK, the Modern Slavery Act 2015 has been introduced. This is the second piece of anti-slavery legislation in 200 years. The Act gives law enforcement the tools to fight modern slavery, ensure perpetrators receive suitably severe punishments for these crimes, and enhances support and protection for victims. The UK government has a scheme of assessment and support for trafficked people, but currently only a small proportion are getting this support; approximately 20-25% of victims.

Those who present in healthcare settings may have little or no engagement with any other services. Health professionals therefore have an important role to play in identifying and caring for trafficked people and in referring them for further support and by being able to support them to report to the appropriate authorities.

As part of this, Public Health England is rolling out training to the PHE workforce on identifying and supporting victims of modern slavery, of which some of the lessons are here to further raise awareness.

The relevance to public health is multitude and includes long term multiple injuries, mental health, physical health, sexual trauma, sexually transmitted infections, late access to maternity care, unplanned pregnancies, disordered eating or poor nutrition, self-harm, dental pain, fatigue, post-traumatic stress disorder, psychiatric or psychological distress, back pain, stomach pain, skin problems, headaches, and dizzy spells.

As public health professionals and as citizens in our countries we all have a responsibility to look for the signs of modern slavery and to seek support for these vulnerable people. It is usually a combination of triggers, an inconsistent story and a pattern of symptoms that may cause you to suspect trafficking. Signs to look for in an individual include being accompanied by someone who is controlling, being withdrawn, submissive, vague, inconsistent, old and untreated injuries, no registration with a GP, nursery, or school, frequent movements of location, neglect, or poor English. Importantly, trafficked people may not self-identify as victims of modern slavery, can feel fear or shame in revealing their experiences or may be limited through language barriers. Support and advice is offered by the Salvation Army for adults and local safeguarding leads for children in the UK.

As public health professionals we have a responsibility to know the signs of modern slavery, and know where to go, and to share and inform our wider workforce and colleagues who work directly with the public.
_________________________

References

  1. Modern Slavery Act 2015. Accessed on 11/10/2017 http://www.legislation.gov.uk/ukpga/2015/30/contents/enacted
  2. Department of Health, 2015. Supporting victims of modern slavery through healthcare services. Accessed on 11/10/2017 https://www.gov.uk/government/news/supporting-victims-of-modern-slavery-through-healthcare-services
  3. Public Health England. 2017. Human trafficking: migrant health guide. Accessed on 11/10/2017 https://www.gov.uk/guidance/human-trafficking-migrant-health-guide
  4. department of Health. 2015. Identifying and supporting victims of modern slavery: guidance for health staff. Accessed on 11/10/2017 https://www.gov.uk/government/publications/identifying-and-supporting-victims-of-human-trafficking-guidance-for-health-staff/identifying-and-supporting-victims-of-modern-slavery-guidance-for-health-staff

_________________________

Karen Buckley
Public Health Specialty Registrar, UK

(As published in EuroNews #13)

Portuguese seasonal influenza 2017/2018

(U.S. Navy photo by Mass Communication Specialist Seaman Cole C. Pielop / Released)

Based on the analysis of influenza virus activity in previous seasons, every year WHO launches a recommendation on the strains to be included in the trivalent and quadrivalent influenza virus vaccine (in March for the Northern Hemisphere and September for the Southern Hemisphere). The need to update this vaccine is due to phenomena of antigenic derivation of the virus that, like the previous issue, obliges the annual study of the vaccine that will present greater coverage. Based on circulating types and subtypes, this year a viral strain A (H1N1)pdm09 identical to A/Michigan/45/2015 was recommended for the trivalent vaccine; a virus strain A (H3N2) identical to A/Hong Kong/4801/2014; and a viral strain B (Victoria strain) identical to B/Brisbane/60/2008.

The quadrivalent vaccine contains the three viruses described above, and in addition another strain of virus B/Phuket/3073/2013. (1) Evaluating sentinel sites until December 2017, there was a dominance of virus B circulating in relation to type A. Of the latter, the most prevalent subtype with about 2/3 of detected cases was A (H3N2), and the remaining third H1N1 subtype. In the same surveillance period last year, type A (H3N2) virus circulated almost exclusively, with high immunity expected; however, the presence of emerging sub-strains and variants that were not covered by this year vaccine could be possible the source of suboptimal coverage. Among B viruses, type B/Yamagata was almost exclusive with 85% and the remaining 15%, type B/Victoria. For the 4th consecutive year, the trivalent influenza vaccine does not correspond to the circulating B virus subtypes, since most of the prevalent B virus strains, Yamagata, are antigenic and genetically related to B/Phuket, which is only included in the quadrivalent vaccine. In this sense, and to increase vaccination coverage of the type B virus in the coming years, ECDC advises the use of the quadrivalent vaccine. (2) (3)

Another factor to be discussed that may be among the causes of lower vaccination coverage is due to the use of eggs in vaccines production. This substrate may interact with different groups of aminoacids present and consequently, alter proteins responsible for the antibody receptors, creating minor viral amendments that may change the effectiveness of the vaccine. (4)

Influenza virus vaccine is the most effective prophylactic measure against influenza severity. Thousands of vaccines are distributed in primary health care, completely free of charge to priority groups such as population over 65 years of age, chronic and immunosuppressed patients, pregnant women, health professionals and other caregivers. During flu season and up to the first week of 2018, approximately 478,291 influenza vaccines were administered in Portugal northern health region. Along with this measure, it is also recommended to conduct respiratory etiquette and hand hygiene, as well as the use of appropriate face masks for patients diagnosed or with symptoms suggestive of influenza. (3) (5) (6)

_________________________

References

  1. World Health Organization. Recommended composition of influenza virus vaccines for use in the 2017- 2018 northern hemisphere influenza season. http://www.who.int. [Online] Março 2, 2017. http://www.who.int/influenza/vaccines/virus/recommendations/201703_recommendation.pdf?ua=1..
  2. European Centre for Disease Prevention and Control. Risk assessment for seasonal influenza, EU/EEA. Estocolmo, Estocolmo, Suécia : s.n., Dezembro 20, 2017.
  3. Administração Regional de Saúde do Norte, Departamento de Saúde Pública. Gripe sazonal – vigilância epidemiológica – Semana 40 de 2017 a semana de 1 de 2018. ARS Norte. [Online] Outubro-Janeiro 2017-2018. www.arsnorte.min-saude.pt.
  4. Paules, Catharine I, et al. Chasing Seasonal Influenza — The Need for a Universal Influenza Vaccine. N Negl J Med. DOI: 10.1056/NEJMp1714916, 2018, Vols. 378:7-9.
  5. Centro Emergências de Saúde Pública. RONDA número 2. Lisboa : Direção Geral da Saúde, 2018.
  6. Direção Geral da Saúde. Vacinação contra a gripe – Época 2017/2018. Lisboa : s.n., Setembro 26, 2017. Orientação nº 018/2017 de 26/09/2017.

_________________________

Mariana Perez Duque
Public Health Resident
West Porto Public Health Unit, Portugal

(As published in EuroNews #13)