Tag: Portugal

In Portugal, as in the rest of Europe, the incidence of cancer has been steadily increasing at a rate of about 3% per year.^1,2 This increase is mainly related to the aging of the population and with changes in habits and lifestyles.³

According to the 2018 edition of Health at a Glance: Europe report (Organization for Economic Co-operation and Development – OECD), Portugal has one the lowest avoidable mortality rates in Europe, reflecting greater efficacy in the treatment of patients.⁴

However, cancer disease remains the second leading cause of death in Portugal after cardiovascular disease^5,6, and the leading cause of premature death (defined as death before the age of 70).⁷

Colorectal cancer is currently one of the major forms of cancer in the world, with significant mortality and morbidity associated. In general, it is more common in older people (most patients are over 60 years at the time of diagnosis, being unusual in people with less than 40 years), in males and in urbanized regions.

According to the latest data from the International Agency for Research on Cancer (World Health Organization), colorectal cancer is currently the third most frequent type of cancer in the world and the second largest cause of death by cancer.

In Europe, it is the second most common type of cancer and the second deadliest. In Portugal, it is the second most frequent type of cancer in males (18,8% of the new cases, after prostate cancer) and females (16,2% of the new cases, after breast cancer) but ranks first in the most prevalent types of cancer for both genders.⁸

In 2018, Portugal has diagnosed 10 270 new cases of colorectal cancer (more than 20 cases per day), corresponding to 17,6% of the total number of new cases of cancer in the country.8 Despite the increasing therapeutic success in oncological disease, the number of deaths caused by this type of cancer has been increasing, especially in the most advanced ages.5,6 It is currently the second most deadly type of cancer (following lung cancer), accounting for approximately 4214 deaths (about 12 individuals per day)⁸ and about 12 years of potential life lost.⁹

The reduction of the mortality and morbidity associated with oncological disease depends mainly on preventive strategies and the early detection of the disease. However, the early stages of colorectal cancer are usually asymptomatic or produce little symptoms. The first manifestation of disease is often the asymptomatic loss of small amounts of blood in the stool, not visible to the naked eye, making the early detection difficult. For this reason, many countries now offer systematic population screening programs.

Most cancers of the colon and rectum develop from polyps or adenomas. These lesions are benign but have a significant risk of developing dysplasia, and therefore are considered pre-malignant. The screening programs aim to detect cancer in its initial phase but also to identify and remove these precursor lesions.

Due to the increasing number of cases, the screening for colorectal cancer is now considered a Public Health priority in Europe, and Portugal makes no exception.

Although the significance of the colorectal cancer screening program is unanimously proven (it has the potential do reduce mortality rates by at least 20%)³, there is no international consensus on the methodology that should be used. The strategies vary according to the human and financial resources available and the characteristics of each country. The most validated diagnostic exams currently in use are fecal occult blood tests (FOBT), rectosigmoidoscopy and complete colonoscopy. The fecal immunochemical test (FIT) is currently the most commonly used primary screening test worldwide and has been shown to contribute to increased participation rates, with appropriate sensitivity and cost-effectiveness¹⁰.

Portugal follows the European guidelines and has been developing the foundations for the implementation of a comprehensive population screening program. Thus, in Portugal, screening should be offered to the asymptomatic population aged between 50 and 74 years. As in most European countries, the primary screening test is the FIT, performed every 2 years. The convocation of patients for screening is ensured through their General Practitioners¹¹.

In case of a positive result in the FIT (cut off of 100 ng/mL), the patient should be referred for colonoscopy, under informed consent and within the scope of the Portugal National Health Service, in an average period of no more than 30 days.

The referral algorithm after colonoscopy varies depending on the result of the exam and is performed according to the recommendations of the European Society of Gastrointestinal Endoscopy (ESGE)^11.

Population-based screening programs for cancer have evolved significantly in Portugal during the last few years, with expansion of the geographic coverage, increased numbers of patients screened, and significant improvement in adherence rates. However, screening for colorectal cancer continues to present low countrywide coverage (about 19%)¹, with significant regional asymmetry.

Portugal is currently making efforts to extend colorectal cancer screening throughout the country and to create the channels to adequately screen all the eligible individuals. As a result of the acknowledgement as a Public Health priority and the ongoing efforts, it is expected that in a few years, Portugal will be able to effectively reduce this problem.

Fábio Ricardo Elias Sousa Gomes

PH resident Aveiro, Portugal

References:

1. Portugal. Ministério da Saúde. Direção-Geral da Saúde. Programa Nacional para as Doenças Oncológicas 2017. Lisboa: Direção-Geral da Saúde; 2017.
2. Portugal. Ministério da Saúde. Direção-Geral da Saúde. Direção de Serviços de Informação e Análise. A Saúde dos Portugueses 2016. Lisboa: Direção-Geral da Saúde; 2016.
3. Portugal. Ministério da Saúde. Direção-Geral da Saúde. Relatório de Monitorização e Avaliação dos Rastreios Oncológicos 2016. Lisboa: Direção-Geral da Saúde; 2017.
4. Organisation for Economic Co-operation and Development. OECD Health Division. Health at a Glance: Europe 2018. Paris: OECD Publishing; 2018.
5. Portugal. Instituto Nacional de Estatística. Causas de morte 2016. Lisboa: Instituto Nacional de Estatística; 2018.

Access to health services in the prison system is conditioned by legal barriers, social marginalization and stigma which can increase infectious diseases among the prison population¹.

The prison population is different from other populations and it’s in a situation of increased vulnerability. There are several factors that contribute to this, mainly: more exposure to violence; transmission of infectious diseases; increased unprotected sexual, confinement and overpopulation; difficulties in the patients flow up¹.

The number of prisoners in Portugal is about 14.000 on 2017, for a theoretical capacity of approximately 13.000, generating, thus, a panorama of indisputable overcrowding of the prison system. In addition there is also a high turn-over of inmates². The most relevant characteristics of Portuguese prisoners are summarized in Table 1 and Figure 1.

Figure 1. Prisoners, by age. Portugal 2017²

In order to achieve the goals to 2020 outlined on Onusida/Unaids and reduce the morbimortality of viral hepatitis, the General Directorate for Reinsertion and Prisional Services (Direção-Geral da Reinserção e dos Serviços Prisionais) and 28 hospitals of the National Health Service (SNS) will sign a protocol for the treatment of human immunodeficiency virus (HIV) and viral hepatitis infections in the prison population, extending to the whole country the pilot project that runs between the Hospital de São João in Porto and the prison of Custóias.

This pilot project started on january 2017, in order to promote appropriate diagnostic procedures and to provide medication to cure hepatitis C.

This initiative enabled the elimination of Hepatitis C in prisons in Custóias and Santa Cruz do Bispo and is now being expanded geographically and to include other viral hepatitis and HIV⁴.

Table 1. Characteristics of the Portuguese Prison Population, Portugal, 2017^2,3

Up until now, prisoners were subject to security procedures when traveling to healthcare facilities, which caused constraints to clinical observation. From now on they will be treated in the prison itself. This new model will allow physicians – infecciologists, gastroenterologists and internists – to move to prisons to care for the HIV-infected, hepatitis B and C prison population of 45 prison facilities across the continent. In addition, screening will be done at the entrance, during and at the end of the sentence.

Thus, it is expected that this protocol will shape a new approach to health care for infectious diseases in prisons.

Tiago Carvalho

Public Health Resident, Portugal

José Rodrigues

Public Health Resident, Portugal

References:

1. Sousa KAA, Araújo TME, Teles SA, Rangel EML, Nery IS, Sousa KAA, et al. Fatores associados à prevalência do vírus da imunodeficiência humana em população privada de liberdade. Rev da Esc Enferm da USP. 2017 Dec 18 [cited 2018 Aug 24];51(0)
2. PORDATA- Justiça e Segurança: Prisões [Internet]. [cited 2018 Aug 14]. Available from: https://www.pordata.pt/Subtema/Portugal/Pris%C3%B5es-60
3. Direção-Geral de Saúde. Infeção VIH e Sida- Desafios e estratégias. Lisboa: Direção Geral da Saúde; 2018
4. Hospital de São João- Projeto do São João de eliminação da Hepatite C nas prisões replicado a todo o país [Internet]. [cited 2018 Aug 31]. Available from: http://portal-chsj.min-saude.pt/frontoffice/pages/16?news_id=537

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)

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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.

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

(As published in EuroNews #13)