Leishmaniases are human and animal parasitic diseases transmitted by phlebotomine sand flies. Globalization is an important driver of the burden and in the current dynamics of these diseases. A systematic review of articles published between 2000 and 2021 was conducted using the PubMed search engine to identify the epidemiology and clinical management of imported human leishmaniases as a fundamental step to better manage individual cases and traveler and migrant health from a global perspective. A total of 275 articles were selected, representing 10,341 human imported cases. Identified drivers of changing patterns in epidemiology include conflict and war, as well as host factors, such as immunosuppression, natural and iatrogenic. Leishmania species diversity associated with different clinical presentations implies diagnostic and treatment strategies often complex to select and apply, especially in non-endemic settings. Thus, diagnostic and management algorithms for medical clinical decision support are proposed. Increased surveillance of non-endemic cases, whether in vulnerable populations such as refugees/migrants and immunocompromised individuals or travelers, could improve individual health and mitigate the public health risk of introducing Leishmania species into new areas.

Background: Asymptomatic infection is the most common outcome of exposure to Leishmania parasites. In the Mediterranean region, where Leishmania infantum is endemic, studies on the prevalence of asymptomatic infection have often relied on serological testing in blood donors. In Spain, regional studies have shown seroprevalence in blood donors between 1 and 8%; in Portugal, values of 0 and 2% were suggested by two localized studies, in different populations. The purpose of this study was (i) to estimate the prevalence of asymptomatic Leishmania infection in blood donors in mainland Portugal, and (ii) to study the association between the detection of antibodies to Leishmania and sociodemographic factors, and also the knowledge, perceptions and practices (KPP) of the blood donors regarding leishmaniasis. Methods: A cross-sectional study targeted the population of people who donated blood in mainland Portugal. Participants, distributed proportionally by municipality and aged between 18 and 65 years, were selected randomly in 347 blood collection points between February and June 2022, and completed a sociodemographic and a KPP questionnaire. Detection of anti-Leishmania antibodies in serum was performed using an ELISA commercial kit. Individual KPP scores were calculated by adding grades defined for each question. Results: Globally, 201/3763 samples were positive. The estimated national true seroprevalence was 4.8% (95% CI 4.1–5.5%). The proportion of positive results was significantly different between NUTS (Nomenclature of Territorial Units for Statistics) regions. Models suggested that seropositivity was significantly higher in male sex, people older than 25 years, or residing in the Centro NUTS2 region, but not in dog owners nor people with lower KPP scores. Overall, 72.3% of participants had previously heard of leishmaniasis and, in multivariate analysis, a higher Knowledge score was associated with age 25–40 years, female sex, ownership of dogs, and higher education. Conclusions: Global estimated true seroprevalence (4.8%) was similar to previous regional studies in blood donors in neighboring Spain. Higher seroprevalence values in the NUTS2 Centro region were consistent with incidence data from humans and seroprevalence studies in dogs. On the other hand, the low values in the Alentejo and the high values in the northern subregions may be the result of geographical shifts in parasite circulation due to climate change and should prompt localized and integrated, vector, canine, and human research, following a One Health approach. Graphical

Background: Control of leishmaniasis in the Mediterranean Basin relies on the active contributions from researchers in the fields of animal, human and environmental health. The application of knowledge, perceptions and practices (KPP) questionnaires to health students and professionals in Europe could be fundamental to identify and explore gaps in KPP, highlighting the diversity of conceptions related to this disease between students and professionals active in (One) Health. The objective of this study was to characterize and compare the current knowledge, perceptions and practices regarding leishmaniasis among subgroups of students and health professionals in Portugal through the application of an online questionnaire. Methods: A cross-sectional study targeted the population of health students and professionals in Portugal, including students in medicine, veterinary medicine and environmental health, physicians, veterinarians and environmental health technicians. Potential participants were approached by email via universities and professional societies and organizations and provided with the link to access the online questionnaire. Answers to the self-administered sociodemographic and KPP questionnaire were collected between July and December 2022. Individual KPP scores were calculated by summing grades defined for each question. Logistic regression models were used to search for potential associations, and the results were expressed at estimated crude and adjusted odds ratios with 95% confidence intervals. Results: In total, 486 participants were included in this study: 254 students and 232 professionals. Overall, 75% of the participants reported having heard of both human and animal leishmaniasis, and > 80% reported hearing about the disease during their course work (although this was significantly lower among those in the field of environmental health). Around 90% of participants identified the pathogenic agent as a parasite, and an arthropod bite was identified as the main route of transmission by > 95%. Animal leishmaniasis was considered to be diagnosed in Portugal by 87% of participants and human leishmaniasis by only 69%. The main barriers pointed out by professionals to the control of leishmaniasis were: lack of knowledge in the general population, failures in the early diagnosis and treatment of diseased animals, absence/inefficacy of vector control programs and lack of knowledge in human health professionals. Median knowledge and perception scores were higher among professionals in the animal health field and higher in professionals than in students. Median practice scores were not significantly different between groups and subgroups. The multivariate analysis revealed that a longer period of study (for students) and having seen cases of leishmaniasis (for physicians) were associated with above-mentioned median knowledge score. Conclusions: Most health students and professionals are knowledgeable about the cause and transmission route of leishmaniasis. However, recognition of the disease as autochthonous in humans is less common, highlighting the importance of promoting an approach to this infection through a One-Health lens. A national structured plan to control leishmaniasis could overcome some of the barriers pointed out by professionals, namely by implementing systematic phlebotomine surveillance and integrated reporting of animal and human cases of disease. Graphical

Leishmania infantum, a zoonotic vector-born parasite, is endemic in the Mediterranean region, presenting mostly as visceral (VL), but also as cutaneous (CL) and mucosal leishmaniasis (ML). This study aimed to describe the epidemiological and clinical aspects of the CL and ML cases diagnosed in mainland Portugal between 2010 and 2020. Collaboration was requested from every hospital of the Portuguese National Health System. Cases were screened through a search of diagnostic discharge codes or positive laboratory results for Leishmania infection. Simultaneously, a comprehensive literature search was performed. Descriptive statistics and hypothesis testing were performed using IBM^® SPSS^® Statistics. A total of 43 CL and 7 ML cases were identified, with a predominance of autochthonous cases (86%). In CL, immunosuppressed individuals constituted a significant proportion of patients (48%), and in this group, disseminated CL (22%) and simultaneous VL (54%) were common. In autochthonous cases, lesions, mostly papules/nodules (62%), were frequently observed on the head (48%). The approach to treatment was very heterogeneous. ML cases were all autochthonous, were diagnosed primarily in older immunosuppressed individuals, and were generally treated with liposomal amphotericin B. The findings suggest a need for enhanced surveillance and reporting, clinical awareness, and diagnostic capacity of these forms of leishmaniasis to mitigate underdiagnosis and improve patient outcomes. A holistic One Health approach is advocated to address the multifaceted challenges posed by leishmaniases in Portugal and beyond.

The genus Orthoflavivirus includes several mosquito-borne pathogenic viruses, notably West Nile virus (WNV), which is endemic to the Mediterranean region. In Portugal, WNV circulation has been documented in equines, birds and mosquitoes, however human cases remain rare and no recent human seroprevalence studies have been conducted. This study aimed to estimate the national and regional seroprevalence of WNV among blood donors in mainland Portugal and explore associations with sociodemographic factors. A cross-sectional study conducted in 2022 included 3593 blood donors from across mainland Portugal. Serum samples were tested for WNV immunoglobulin G (IgG) by enzyme-linked immunosorbent assay (ELISA) and positive and borderline samples were confirmed using a virus neutralization test. Sociodemographic data were collected through a structured paper questionnaire. Statistical analyses, including multivariate logistic regression, identified factors associated with seropositivity. A total of 55 samples (1.5%) tested positive, and 21 samples (0.6%) were classified as borderline for WNV antibodies by ELISA. Of these, 47 were confirmed by viral neutralization, giving an estimated national seroprevalence of 1.4%. Significant regional variation was noted, with higher seroprevalence observed in the Beira Baixa, Grande Lisboa and Médio Tejo regions. Some seropositive individuals were identified in northern coastal regions such as Ave, Cávado and Área Metropolitana do Porto. In multivariate analysis, geographical area of residence was the only factor associated with seropositivity. This study highlights regions at potential higher risk for human WNV exposure, primarily in the southern half of Portugal. Continued and integrated surveillance is crucial to inform public health strategies to mitigate WNV transmission risks in these regions, as well as in other regions where WNV may be emerging as a relevant One Health concern. Implementing preventive measures for both animals and humans is critical to minimizing exposure and infection, and further confirmatory studies using virus neutralization tests will be important for refining these estimates.

This study aimed to describe the epidemiology, clinical presentation, and management of Campylobacter sp. and Salmonella sp. infections in a tertiary hospital in Northern Portugal (2010–2020) and identify factors associated with reporting, invasive disease, and hospitalization. A retrospective review included patients with Campylobacter sp. (2015–2020) or Salmonella sp. infections (2010–2020). Reported cases were cross-referenced with the National Epidemiological Surveillance System. A total of 742 patients were included: 342 with Campylobacter sp., 392 with non-typhoidal Salmonella (NTS), and 15 with typhoidal Salmonella (TS). Immunosuppression was present in 16.7% of cases. NTS infections were invasive in 21.4% of cases, compared to 4.0% for Campylobacter. Macrolide resistance in Campylobacter reached 10%, particularly in C. coli, while multidrug resistance (MDR) was observed in 37.8% of NTS isolates. Immunocompromised patients accounted for over 70% of relapses in Campylobacter disease. Reporting rates were low: 32.8% for NTS, 30.6% for Campylobacter, and 14.3% for TS. Reporting was associated with male sex, no immunosuppression, hospitalization, and non-MDR organisms. In conclusion, immunocompromised patients face higher risks of invasive and relapsing disease. High rates of MDR in NTS limit treatment options. Underreporting remains significant, underscoring the need for improved awareness and reporting to inform public health strategies.