Wastewater-based epidemiology offers a non-invasive, symptom-independent modality to complement clinical surveillance and capture emerging biosecurity threats. In response to the 2026 Bundibugyo ebolavirus outbreak in the Democratic Republic of the Congo and Uganda, we developed and validated a Reverse Transcription Quantitative Polymerase Chain Reaction (RT-qPCR) assay optimized for environmental matrices, achieving a limit of detection of 6.45 copies per reaction. Rather than resource-intensive, community-wide asymptomatic testing, we propose a targeted, risk-tiered global consensus framework for use in low-and middle-income countries, focusing on the regions affected by the known clinical outbreak. We also propose a consensus set of gene-specific primers and probes that will ensure data comparability, alongside a sampling strategy that prioritises surveillance at critical transportation hubs, land borders, and refugee camps to serve as an early-warning system. By standardizing molecular tools for Bundibugyo ebolavirus detection in environmental matrices, where no validated assays previously existed, this framework provides a scalable model for cross-border pathogen tracking while preserving Ministry of Health data ownership. Dedicated international investment in early-warning environmental surveillance is now needed to strengthen regional epidemic preparedness without compromising frontline clinical care.

The Strategic Plan for Cardiovascular Health in Portugal is an initiative of the Portuguese Society of Cardiology, developed together with the European Society of Cardiology to create a European Cardiovascular Health Plan, an initiative which has now been endorsed by the Council of the European Union. Building upon its conceptual framework, the Portuguese Society of Cardiology moved to the implementation phase by establishing Working Groups composed of experts in priority areas. Guided by strategic pillars, these groups formulated proposals for action encompassing health promotion, primary prevention and health determinants, screening and early diagnosis, secondary prevention, as well as rehabilitation and quality of life promotion. This document outlines the results and messages from this project.

Arboviral diseases pose major economic and social threats in less economically developed countries (LEDCs), where monitoring is challenging, especially in rapidly growing cities with informal settlements. In this study, we aimed to explore environmental surveillance (ES) in a non-sewered setting as a complement to syndromic surveillance in Maputo, Mozambique. Water samples were collected from nine points along the Infulene River (n = 66) in Maputo, Mozambique from February to September 2023. The presence of arboviruses (Dengue (DENV), Chikungunya (CHIKV), West Nile (WNV), and Usutu (USUV) virus) was determined by RT-qPCR. For the specific detection of CHIKV, two RT-qPCR assays were used: the Nsp1, targeting the non-structural protein 1 gene (nsP1) and the E1, targeting the E1 envelope protein gene (E1). DENV was detected in 82% (54/66) of the samples, with a median viral RNA load of 2.7 × 10-2 (2.2 × 105 copies/L (cp/L)), while CHIKV was detectable in 98% (65/66) of the samples, with a median viral RNA load of 4.8 × 10-2 (2.2 × 105 cp/L) for the nsP1 gene and 8.0 × 10-2 for the E1 gene (4.8 × 105 cp/L), and USUV was detected in 6% (4/66) of the samples at a median viral RNA load of 4.1 × 10-7 (0 cP/L), with viral RNA load in positive samples varying between 1.8 × 10-3 (7.1 × 102 cp/L) and 4.95 × 10-2 (2.1 × 103 cp/L). WNV was not detected throughout the study. The prevalence and concentration varied across sampling dates. Our study demonstrated the potential of ES as a tool for assessing the circulation of arboviruses in Mozambique, where a sewered system is unavailable. Consequently, ES could be expanded from polio surveillance to include other targets in LEDCs.

Background: Legionella species are the causative agent of Legionnaires’ disease and, as ubiquitous waterborne bacteria, are prone to antimicrobial resistance gene (ARG) acquisition and dissemination due to the antimicrobial contamination of natural environments. Given the potential health risks associated with ARGs, it is crucial to assess their presence in the Legionella population. Methods: The ARGs lpeAB and tet56 were detected in 348 samples, isolates, and DNA extracts using conventional PCR. In a subset of lpeAB-positive isolates, azithromycin (AZT) MIC values were obtained using the EUCAST protocol and LpeAB activity was evaluated through an efflux pump inhibition assay. Results: The lpeAB gene was found in 19% (66/348) of samples, with higher detection rates in the L. pneumophila and L. pneumophila sg1 subgroups, at 30% and 41%, respectively. A positive association between lpeAB and L. pneumophila sg1 was found. The MIC values of the lpeAB-positive isolates ranged from 0.064 to 2 mg/L. LpeAB inhibition resulted in 2- and 4-fold MIC reductions in 10 of the 13 isolates analyzed. One sample each of L. longbeacheae and L. bozemanae was found to possess the tet56 gene. Conclusions: The lpeAB gene is predominant in L. pneumophila sg1. A few isolates with the lpeAB gene exhibited MIC values below the EUCAST tentative highest MIC values for wild-type isolates. Expanding ARG monitoring in Legionella is essential to assess the public health risk of Legionnaires’ disease.

Background: Arboviral diseases pose significant economic and social threats, especially in less economically developed countries (LEDCs) where monitoring disease circulation is often challenging. Moreover, many cities in LEDCs are experiencing rapid growth with predominantly unplanned informal settlement, which can facilitate the spread of these diseases. In this study, we aimed to explore environmental surveillance (ES) in a non-sewered setting as a complement to syndromic surveillance in Mozambique. Methods: Water samples were collected from nine points along the Infulene River (n = 66) in the Maputo region of Mozambique over an eight-month period, from February to September 2023. Samples were concentrated using polyethylene glycol, and the presence of arboviruses (Dengue (DENV), Chikungunya (CHIKV), West Nile (WNV), and Usutu (USUV) virus) was determined by RT-qPCR. Findings: DENV was detected in 82% (54/66) of the samples, with a median concentration of 2·2 x 105 copies/L (cp/L) [5·2 x 104 - 5·5 x 105]. CHIKV was detectable in 98% (65/66) of the samples, with a median concentration of 3·5 x 105 cp/L (Nsp1 gene [5·8 x 104 - 6·5 x 105], and E1 gene [1·5 x 105 - 1·2 x 106]), whereas USUV was detected in 6% (4/66) of the samples at a median concentration of 0 cp/L [0 - 0]. WNV was not detected throughout the study. The prevalence and concentration of each virus varied across sampling points and dates. Interpretation: Our study demonstrated the efficacy of ES as a tool for assessing the epidemiological status of arboviruses in Mozambique, where a sewered system is unavailable. Consequently, ES should be expanded from polio surveillance to include other targets in LEDCs. Funding: Fundação para a Ciência e Tecnologia (FCT) and Swedish International Development Cooperation Agency (SIDA). Declaration of Interest: We declare no competing interests.

In response to the rapid emergence and dissemination of antimicrobial resistant bacteria (ARB) and genes (ARGs), integrated surveillance systems are needed to address antimicrobial resistance (AMR) within the One Health Era. Wastewater analyses enable biomarker monitoring at the sewershed level, offering timely insights into pathogen circulation and ARB/ARGs trends originating from different compartments. During two consecutive epidemic waves of the COVID-19 pandemic in Portugal, taxonomic and functional composition of raw urban wastewater from two wastewater treatment plants (WWTPs) representing one million in equivalent population, located in the main urban areas of the country, were profiled by shotgun metagenomics. Hospital wastewater from two central hospitals located in the WWTPs catchment areas were also sequenced. The resistome and virulome were profiled using metagenomic assemblies without taxonomic constraint, and then specifically characterized for ESKAPE pathogens. Urban and hospital wastewater exhibited specific microbiota signatures, Pseudomonadota dominated in the first and Bacteroidota in the latter. Correlation network analyses highlighted 85 (out of top 100) genera co-occurring across samples. The most frequent ARGs were classified in the multidrug, tetracyclines, and Macrolides, Lincosamides, Streptogramins (MLS) classes. Links established between AMR determinants and bacterial hosts evidenced that the diversity and abundance of ARGs is not restricted to ESKAPE, being also highly predominant among emergent enteropathogens, like Aeromonas and Aliarcobacter, or in the iron (II) oxidizer Acidovorax. The Aliarcobacter genus accumulated high abundance of sulphonamides and polymyxins ARGs, while Acinetobacter and Aeromonas hosted the highest abundance of ARGs against beta-lactams. Other bacteria (e.g. Clostridioides, Francisella, Vibrio cholerae) and genes (e.g. vanA-type vancomycin resistance) of public health interest were detected, with targeted monitoring efforts being needed to establish informative baseline data. Altogether, results highlight that wastewater monitoring is a valuable component of pathogen and AMR surveillance in healthy populations, providing a community-representative snapshot of public health trends beyond priority pathogens.

The Strategic Plan for Cardiovascular Health in Portugal is an initiative of the Portuguese Society of Cardiology, aligned with efforts by the European Society of Cardiology and the World Heart Federation to develop national plans, at a local level within the cultural and socio-economic contexts, focused on cardiovascular health. The overarching goal is to promote and ensure the continuous and sustained improvement of cardiovascular health in the Portuguese population. The methodology identified key challenges and opportunities for the medium term, highlighted priority areas for intervention, and proposed strategic lines of action. This article outlines the project's design and establishes a guiding framework for the proposed actions, which will be drawn up by designated expert groups and communicated subsequently.

BACKGROUND:The global distribution and prevalence of arboviral diseases have increased in recent years, driven by factors such as climate change, biodiversity loss, globalisation, and urbanisation. These diseases are often underestimated due to uneven surveillance and unreported asymptomatic cases. Current surveillance relies on vector and clinical surveillance. In this study, we aimed to explore wastewater-based surveillance (WBS) as an additional tool for dengue virus (DENV) and chikungunya virus (CHIKV) tracking. METHODS:In this exploratory surveillance study, WBS was done at eleven wastewater treatment plants in three regions in Portugal (North, Lisboa and Vale do Tejo, and south). Using quantitative RT-PCR, we quantified in raw wastewater the RNA concentrations of DENV and CHIKV (non-structural viral protein 1 [nsP1] and envelope protein [E1] genes) once every 2 weeks for a period of 11 months, between May 16, 2022, and April 19, 2023. Results were normalised with crAssphage (concentration of target viral RNA divided by the concentration of crAssphage DNA) and provided as median normalised viral load. Prevalence (proportion of positive samples) and viral quantities were summarised for the total sampling period, by calendar month, and by seasons. FINDINGS:273 samples were collected from 11 wastewater treatment plants situated across the North (n=75 samples), Lisboa and Vale do Tejo (n=98), and south (n=100) regions of Portugal. DENV was detected in 68 (25%) of 273 samples, with a median viral load of 1·1 × 10-4 (IQR 3·2 × 10-5 to 8·0 × 10-4). CHIKV was detected in 30 (11%) of 273 samples, with median viral loads of 3·1 × 10-4 (1·6 × 10-4 to 6·4 × 10-4; nsP1 gene) and 7·8 × 10-4 (4·2 × 10-4 to 2·0 × 10-³; E1 gene). The pattern of occurrence of CHIKV was similar between regions whereas slight differences were found for DENV. When combining results for the three studied regions, DENV prevalence and viral load had two seasonal peaks (summer and winter) and CHIKV prevalence and viral load had a single peak during March and April of 2023. INTERPRETATION:This study highlights the potential of WBS as a potent tool for gauging the epidemiological landscape of DENV and CHIKV in Portugal, where autochthonous cases have not yet been detected. WBS could serve as an additional element to conventional surveillance approaches, especially in areas where real-time clinical surveillance data are scarce or delayed. FUNDING:EU Emergency Support Instrument and Fundação para a Ciencia e Tecnologia.

As the COVID-19 pandemic reached its peak, many countries implemented genomic surveillance systems to track the evolution and transmission of SARS-CoV-2. Transition from the pandemic to the endemic phase prioritized alternative testing strategies to maintain effective epidemic surveillance at the population level, with less intensive sequencing efforts. One such promising approach was Wastewater-Based Surveillance (WBS), which offers non-invasive, cost-effective means for analysing virus trends at the sewershed level. From 2020 onwards, wastewater has been recognized as an instrumental source of information for public health, with national and international authorities exploring options to implement national wastewater surveillance systems and increasingly relying on WBS as early warning of potential pathogen outbreaks. In Portugal, several pioneer projects joined the academia, water utilities and Public Administration around WBS. To validate WBS as an effective genomic surveillance strategy, it is crucial to collect long term performance data. In this work, we present one year of systematic SARS-CoV-2 wastewater surveillance in Portugal, representing 35 % of the mainland population. We employed two complementary methods for lineage determination - allelic discrimination by RT-PCR and S-gene sequencing. This combination allowed us to monitor variant evolution in near-real-time and identify low-frequency mutations. Over the course of this year-long study, spanning from May 2022 to April 2023, we successfully tracked the dominant Omicron sub-lineages, their progression and evolution, which aligned with concurrent clinical surveillance data. Our results underscore the effectiveness of WBS as a tracking system for virus variants, with the ability to unveil mutations undetected via massive sequencing of clinical samples from Portugal, demonstrating the ability of WBS to uncover new mutations and detect rare genetic variants. Our findings emphasize that knowledge of the genetic diversity of SARS-CoV-2 at the population level can be extended far beyond via the combination of routine clinical genomic surveillance with wastewater sequencing and genotyping.

The United States Centers for Disease Control and Prevention reported a rise in resistant infections after the coronavirus disease 2019 (COVID-19) pandemic started. How and if the pandemic contributed to antibiotic resistance in the larger population is not well understood. Wastewater treatment plants are good locations for environmental surveillance because they can sample entire populations. This study aimed to validate methods used for COVID-19 wastewater surveillance for bacterial targets and to understand how rising COVID-19 cases from October 2020 to February 2021 in Portugal (PT) and King County, Washington contributed to antibiotic resistance genes in wastewater. Primary influent wastewater was collected from two treatment plants in King County and five treatment plants in PT, and hospital effluent was collected from three hospitals in PT. Genomic extracts were tested with the quantitative polymerase chain reaction for antibiotic resistance genes conferring resistance against antibiotics under threat. Random-effect models were fit for log-transformed gene abundances to assess temporal trends. All samples collected tested positive for multiple resistance genes. During the sampling period, mecA statistically significantly increased in King County and PT. No statistical evidence exists of correlation between samples collected in the same Portuguese metro area.

Beach sand harbors a diverse group of microbial organisms that may be of public health concern. Nonetheless, little is known about the presence and distribution of viruses in beach sand. In this study, the first objective was to evaluate the presence of seven viruses (Aichi virus, enterovirus, hepatitis A virus, human adenovirus, norovirus, rotavirus, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) in sands collected at public beaches. The second objective was to assess the spatial distribution of enteric viruses in beach sand. To that end, 27 beach sand samples from different beaches in Portugal were collected between November 2018 and August 2020 and analyzed for the presence of viruses. At seven beaches, samples were collected in the supratidal and intertidal zones. Results show that viruses were detected in 89 % (24/27) of the sand samples. Aichi virus was the most prevalent (74 %). Noroviruses were present in 19 % of the samples (norovirus GI - 15 %, norovirus GII - 4 %). Human adenovirus and enterovirus were detected in 48 % and 22 % of the samples, respectively. Hepatitis A virus and rotavirus were not detected. Similarly, SARS-CoV-2 in beach sand collected during the initial stages of the pandemic was also not detected. The detection of three or more viruses occurred in 15 % of the samples. Concentrations of viruses were as high as 7.2 log copies (cp)/g of sand. Enteric viruses were found in higher prevalence in sand collected from the supratidal zone compared to the intertidal zone. Human adenovirus was detected in 43 % of the supratidal and 14 % in the intertidal samples and Aichi virus in 57 % and 86 % of the intertidal and supratidal areas, respectively. Our findings suggest that beach sand can be a reservoir of enteric viruses, suggesting that it might be a vehicle for disease transmission, particularly for children, the elderly, and immunocompromised users.

The antibacterial properties of cellulose acetate/silver nanoparticles (AgNP) ultrafiltration membranes were correlated with their integral asymmetric porous structures, emphasizing the distinct features of each side of the membranes, that is, the active and porous layers surfaces. Composite membranes were prepared from casting solutions incorporating polyvinylpyrrolidone-covered AgNP using the phase inversion technique. The variation of the ratio acetone/formamide and the AgNP content resulted in a wide range of asymmetric porous structures with different hydraulic permeabilities. Comprehensive studies assessing the antibacterial activity against Escherichia coli (cell death and growth inhibition of bacteria in water) were performed on both membrane surfaces and in E. coli suspensions. The results were correlated with the surface chemical composition assessed by XPS. The silver-free membranes presented a generalized growth of E. coli, which is in contrast with the inhibition patterns displayed by the membranes containing AgNP. For the surface bactericide test, the growth inhibition depends on the accessibility of E. coli to the silver present in the membrane; as the XPS results show, the more permeable membranes (CA30 and CA34 series) have higher silver signal detected by XPS, which is correlated with a higher growth inhibition. On the other hand, the inhibition action is independent of the membrane porous structure when the membrane is deeply immersed in an E. coli inoculated suspension, presenting almost complete growth inhibition.

With the advent of molecular biology diagnostics, different quantitative PCR assays have been developed for use in Source Tracking (ST), with none of them showing 100% specificity and sensitivity. Most studies have been conducted at a regional level and mainly in fecal slurry rather than in animal wastewater. The use of a single molecular assay has most often proven to fall short in discriminating with precision the sources of fecal contamination. This work is a multicenter European ST study to compare bacterial and mitochondrial molecular assays and was set to evaluate the efficiency of nine previously described qPCR assays targeting human-, cow/ ruminant-, pig-, and poultry-associated fecal contamination. The study was conducted in five European countries with seven fecal indicators and nine ST assays being evaluated in a total of 77 samples. Animal fecal slurry samples and human and non-human wastewater samples were analyzed. Fecal indicators measured by culture and qPCR were generally ubiquitous in the samples. The ST qPCR markers performed at high levels in terms of quantitative sensitivity and specificity demonstrating large geographical application. Sensitivity varied between 73% (PLBif) and 100% for the majority of the tested markers. On the other hand, specificity ranged from 53% (CWMit) and 97% (BacR). Animal-associated ST qPCR markers were generally detected in concentrations greater than those found for the respective human-associated qPCR markers, with mean concentration for the Bacteroides qPCR markers varying between 8.74 and 7.22 log10 GC/10 mL for the pig and human markers, respectively. Bacteroides spp. and mitochondrial DNA qPCR markers generally presented higher Spearman's rank coefficient in the pooled fecal samples tested, particularly the human fecal markers with a coefficient of 0.79. The evaluation of the performance of Bacteroides spp., mitochondrial DNA and Bifidobacterium spp. ST qPCR markers support advanced pollution monitoring of impaired aquatic environments, aiming to elaborate strategies for targetoriented water quality management.

The COVID-19 pandemic caused by the SARS-CoV-2 virus led to changes in the lifestyle and human behaviour, which resulted in different consumption patterns of some classes of pharmaceuticals including curative, symptom-relieving, and psychotropic drugs. The trends in the consumption of these compounds are related to their concentrations in wastewater systems, since incompletely metabolised drugs (or their metabolites back transformed into the parental form) may be detected and quantified by analytical methods. Due to the limitations of conventional Wastewater Treatment Plants (WWTP) pharmaceutical compounds can end up in water courses or accumulate in sludge, which represents a serious concern due to their potential impact in ecosystems and public health.In this work, eight pharmaceuticals from five therapeutic classes were analysed in wastewater and sludge samples collected in two WWTP located in the Northern Portugal, during the third COVID-19 epidemic wave in Portugal. The two WWTP demonstrated a similar pattern with respect to the concentration levels in that period. However, the drugs loads reaching each WWTP were dissimilar when normalising the concentrations to the inlet flow rate. Acetaminophen (ACET) was the compound detected at highest concentrations in aqueous samples of both WWTP in January (between 98. 516 μg L-1 in WWTP2 and 123. 506 μg L-1in WWTP1). The concentrations determined in the sludge samples were below 1.65 µg g-1 in both WWTP, the highest value being found for azithromycin (AZT) in WWTP1. It was not possible to establish a clear relationship between the incidence of COVID-19 cases in the sewer catchment and the concentration of drugs detected in the same period. However, looking at the data obtained, the high incidence of COVID-19 in January 2021 is in line with the high concentration of drugs detected in the aqueous and sludge samples but prediction of drug load from viral load data was unfeasible.

In Portugal, up to 38% of the population has cardiovascular disease, which highlights the importance of primary health care (PHC) in its management. Adequate management of people with cardiovascular disease often requires hospital referral for a cardiology consultation. However, it is not always easy to ascertain which situations should be referred, especially given that PHC does not have access to all diagnostic exams recommended by international guidelines, such as natriuretic peptides in heart failure or computed tomography coronary angiogram in chronic coronary syndromes, among others. The aim of this document is to describe a practical approach to the most frequent heart diseases that may require a referral for a hospital cardiology consultation. Thus, in the different chapters, the recommendations for referral are highlighted generically according to group of disease, as well as, albeit briefly, the initial clinical approach within the scope of PHC for a differential diagnosis and more efficient follow-up. A modified Metaplan methodology was used. A panel of 4 cardiology specialists and 3 specialists in General and Family Medicine developed this document, which should not be taken as an official guideline, but as additional guidance for the correct referral of patients. It is therefore advisable to validate these recommendations locally with the referral hospital, as well as to be aware of the respective international and national guidelines. Em Portugal, até 38% da população sofre de doença cardiovascular, o que salienta a importância dos cuidados de saúde primários (CSP) na sua gestão. A gestão adequada da pessoa com doença cardiovascular obriga frequentemente à referenciação hospitalar para consulta de cardiologia. Contudo, nem sempre é fácil distinguir quais as situações mais prementes, principalmente tendo em conta que os CSP não têm acesso a todos os exames complementares de diagnóstico recomendados pelas guidelines internacionais, como por exemplo péptidos natriuréticos na insuficiência cardíaca ou angiografia por tomografia computorizada cardíaca nas síndromes coronárias crónicas, entre outros. O objetivo deste documento é descrever uma abordagem prática às patologias do foro cardiológico mais frequentes que podem requerer uma referenciação para consulta hospitalar de cardiologia. Assim, nos diferentes capítulos são destacadas as recomendações de referenciação de forma genérica, por grupo de patologias, bem como, ainda que de forma sucinta, a abordagem clínica inicial no âmbito dos CSP para um diagnóstico diferencial e acompanhamento crónico mais eficiente. Foi utilizada uma metodologia Metaplan modificada reunindo um painel de quatro especialistas em cardiologia e três especialistas em medicina geral e familiar que desenvolveram este documento, o qual deve ser entendido não como uma norma oficial, mas sim como um instrumento de orientação adicional para o correto encaminhamento dos doentes. É por isso aconselhada a validação local destas recomendações com o hospital de referência, bem como a leitura das respetivas guidelines internacionais e nacionais.

Climate change is altering the habits of the population. Extensive drought periods and overuse of potable water led to significant water shortages in many different places. Therefore, new water sources are necessary for usage in applications where the microbiological and chemical water quality demands are less stringent, as for agriculture. In this study, we planted, germinated, and grew vegetables/fruits (cherry tomato, lettuce, and carrot) using three types of potential waters for irrigation: secondary-treated wastewater, chlorine-treated wastewater, and green wall-treated greywater, to observe potential health risks of foodstuff consumption. In this study the waters and crops were analyzed for three taxonomic groups: bacteria, enteric viruses, and protozoa. Enteric viruses, human Norovirus I (hNoVGI) and Enterovirus (EntV), were detected in tomato and carrots irrigated with secondary-treated and chlorine-treated wastewater, in concentrations as high as 2.63 log genome units (GU)/g. On the other hand, Aichi viruses were detected in lettuce. Bacteria and protozoa remained undetected in all fresh produce although being detected in both types of wastewaters. Fresh produce irrigated with green wall-treated greywater were free from the chosen pathogens. This suggests that green wall-treated greywater may be a valuable option for crop irrigation, directly impacting the cities of the future vision, and the circular and green economy concepts. On the other hand, this work demonstrates that further advancement is still necessary to improve reclaimed water to the point where it no longer constitutes risk of foodborne diseases and to human health.

Water microbial contamination is one of the major threats to human health. The study focus is on Infulene River Basin, a urban catchment with mainly informal settlements, with limited water supply and sanitation. In the catchment there are two wastewater treatment plants, one hospital and beer factory located on the banks of the main stream; water from this stream is used for urban agriculture and domestic uses by some dwellers. These factors present a significant health risk from water-borne diseases. At the moment there is limited knowledge about the level of microbial contamination of the different sources of water at the disposal of the communities. Thus, a preliminary study on fecal microbial contamination was conducted targeting the Infulene River and the drainage system from the nearby Maputo city draining into the system, with additional investigation on the drinking water provided by the city water supply company. The quantification of Total Coliforms (TC) and Escherichia coli (EC) was conducted at several sampling locations. Results were compared with official drinking water standards. Eighty two percent (82%) and 61% of Infulene river water and drainage water samples were positive for TC (105 to 109 NPN/100 mL) and EC (105 to 107 NPN/100 mL), respectively. For drinking water samples, 63% and 23% were positive for TC (up to 6000 NPN/100 mL) and EC (up to 1000 NPN/100 mL), respectively. Higher microbial contamination was found in neighborhoods with the poorest sanitation and shallow groundwater, i.e., Chamanculo, Xipamanine, Mafalala, Aeroporto and Maxaquene, a situation that was more expressive during the rainy season. Overall, the study confirmed the high vulnerability to microbial contamination of all sources investigated due to poor sanitation and lack of drainage infrastructure. The risks to human health might be even higher considering that contaminated water is used for gardening of vegetable watering and domestic use.

Objectives In ST-segment elevation myocardial infarction (STEMI), time delay between symptom onset and treatment is critical to improve outcome. The expected transport delay between patient location and percutaneous coronary intervention (PCI) centre is paramount for choosing the adequate reperfusion therapy. The “Centro” region of Portugal has heterogeneity in PCI assess due to geographical reasons. We aimed to explore time delays between regions using process mining tools. Methods Retrospective observational analysis of patients with STEMI from the Portuguese Registry of Acute Coronary Syndromes. We collected information on geographical area of symptom onset, reperfusion option, and in-hospital mortality. We built a national and a regional patient's flow models by using a process mining methodology based on parallel activity-based log inference algorithm. Results Totally, 8956 patients (75% male, 48% from 51 to 70 years) were included in the national model. Most patients (73%) had primary PCI, with the median time between admission and treatment <120 minutes in every region; “Centro” had the longest delay. In the regional model corresponding to the “Centro” region of Portugal divided by districts, only 61% had primary PCI, with “Guarda” (05:04) and “Castelo Branco” (06:50) showing longer delays between diagnosis and reperfusion than “Coimbra” (01:19). For both models, in-hospital mortality was higher for those without reperfusion therapy compared to PCI and fibrinolysis. Conclusion Process mining tools help to understand referencing networks visually, easily highlighting its inefficiencies and potential needs for improvement. A new PCI centre in the “Centro” region is critical to offer timely first-line treatment to their population.

In Portugal, up to 38% of the population has cardiovascular disease, which highlights the importance of primary health care (PHC) in its management.