Volume 12 - 2024 | https://doi.org/10.3389/fpubh.2024.1389057 Vertical integration models aim for the integration of services from different levels of care (e.g. and secondary care) with the objective of increasing coordination and continuity of care as well as improving efficiency This paper provides a view of the Portuguese National Health Service (NHS) healthcare providers’ vertical integration operationalized by the Portuguese NHS Executive Board during 2023 and 2024 This paper also aims to contribute to the discussion regarding the opportunities and constraints posed by public healthcare organizations vertical integration reforms The Portuguese NHS operationalized the development and generalization of Local Health Units management model throughout the country The same institutions are now responsible for both the primary care and the hospital care provided by public services in each geographic area This 2024 reform also changed the NHS organic and organizational structures opening paths to streamline the continuum of care it will be important to ensure adequate monitoring and support with the participation of healthcare services as well as community structures and other stakeholders to promote an effective integration of care Integration of care is emerging as a tool for health sector reform around the world (37) to improve system efficiency and effectiveness, population health outcomes, continuity of care, as well as access to healthcare, both primary and secondary (37) The concept of integrated care primarily originates from systems theory, which views organizations as hierarchical structures with interconnected parts (7). As organizations become more complex and decentralized with specialization, quality of care may suffer. Pursuing the integration of these specialized structures can therefore lead to increased efficiency and healthcare quality (7, 13) The gains in efficiency and effectiveness can occur in multiple aspects. Integration can lead to less duplication and waste, more flexible service provision, and better coordination and continuity of care. It can encourage more holistic and personalized approaches to health needs, especially for complex patients such as older individuals and those with multiple chronic diseases (4, 7) Integrated care is also considered a strategy to increase continuity of care, with an emphasis on prevention and disease management. This is achieved by shifting the focus of care to the community and primary care, instead of the hospital, and even changing how accident and emergency departments in hospitals operate (14) Worldwide efforts are being made to increase the integration of care in different formats, ranging from complete integration of the organizations responsible for health and social care to small efforts in decentralized service-delivery networks (6) Supported by the previous experience with vertically integrated healthcare organizations in Portugal and best practices from the literature the Portuguese National Health Services (NHS) Executive Board (EB) is implementing a novel approach in vertical integration The purpose of this article is to present an overview of the literature and the efforts being done in the Portuguese NHS the article aims to contribute to the global discussion on the practical implementation of integration of care in the context of a health system strongly supported by a national health service Integration of care has promising results in reducing length of hospital stays (4), enhancing patient satisfaction (4, 14), increasing perceived quality of care, and enabling access to services (14) the effectiveness of integrated care initiatives hinges on a multitude of factors There is a need for a careful orchestration of the interconnected elements each contributing to the overarching goal of enhancing healthcare delivery and improving patient outcomes • The level and scope of integration, which determine the extent to which services are coordinated across various healthcare domains (13); • Financial incentives that affect, directly or indirectly, integrated care models, which can either foster or hinder collaborative efforts among healthcare providers (13); • The degree of shared decision-making among stakeholders, as it promotes patient-centered approaches and ensures that care plans align with individual needs and preferences (13, 17); • The establishment of robust governance structures, which are essential for promoting cohesive collaboration and ensuring accountability across the care continuum (13, 18); • The development of care paths to specific disease contexts, as different conditions may require tailored approaches to integration (13, 18) While integration efforts hold theoretical benefits their implementation results vary in both benefits and expected disadvantages focusing on specific contexts and implementation methods is crucial Germany’s Gesundes Kinzigtal, a population-based approach that organizes care across all health service sectors in a specific region has also achieved considerable results. A decrease in mortality was measured 2.5 years after enrollment in the program, as well as decreased length of stay, improved patient and provider experience, and decreased cost per patient per year (13) In the Netherlands, a bundled payments system, specific for certain chronic conditions reduced specialist care and enhanced patient and provider experience. However, it presented mixed results for clinical outcomes, mortality, and process indicators and increased costs due to its disease-oriented approach (13) In Spain, the integration of 1 hospital and 7 primary care providers, the provision of cardiology care improved the quality of care related to ischemic heart disease, heart failure, and atrial fibrillation, when compared to usual cardiological care (24) Overall, vertical integration is a promising avenue to increase patient-centered care while still increasing systemic efficiency and effectiveness. Furthermore, attempts with greater range are more promising than focusing only on one disease or group (13). While care integration typically enhances results and quality in health, vigilance is required to mitigate potential inefficiencies, especially when strategic alignment is not promoted (25) Addressing these complexities is crucial for optimizing the outcomes of vertical integration initiatives and mitigating potential adverse effects The diversity of care that the Portuguese NHS provides the highly technical autonomy of its health professionals the increasing healthcare costs and the expectations of a more informed and demanding society are friction points that need to be addressed to create a stronger health system in Portugal it is essential to promote multidimensional integration and increase coordination between teams of health professionals All with a focus on experience and pathways between the different levels of care experienced by users This should include (i) creating greater proximity of institutions in the same geographic area (iii) monitoring and evaluating health policies and (iv) maximizing access and efficiency of the health service response The growing healthcare demands and health workforce specialization led to a considerable fragmentation between healthcare institutions around the country both on the hospital and primary care level (i) conglomerates of hospitals under the same management (ii) healthcare center groupings that in turn would include several kinds of primary care services such as family medicine (iii) Local Health Units that would include all the before mentioned organizations under one management team (iv) as well as specialty oncology hospitals The LHUs are legal entities with administrative, financial, and patrimonial autonomy (32). Hence, their ultimate objective is to enhance the connection between primary healthcare and specialized care. This takes place by integrating the provision and management of all healthcare levels from a given geographical area, ensuring both are housed within the same institution (33) Organogram of the Portuguese National Health Service (SNS) institutions in 2023 (Panel A) and 2024 (Panel B) At the national level, the goal is to optimize service responsiveness through streamlining the organizational structures of the Portuguese NHS, thereby presenting a clear and functional organizational framework (36) The mergers entailed in the reform were addressed through an intensive onboarding process of the institutions that involved 27 working groups with weekly meetings Several of them went further and created participatory processes with the front-line workers to build from the bottom up what each LHU should be and how to organize itself the working groups that developed a business plan for their LHU were motivated by the NHS EB to tailor their plan to the specific characteristics of their population and their professionals The LHUs will redefine the organic architecture of the NHS institutions assuming the assistance response at the level of primary health care and hospital care in an integrated manner This reform considerably enhances and streamlines the construction of NHS instruments for planning and organization through the optimization and integration of care This reorganization will bring closer the point of care and the first level of an executive decision-making body It will also decrease the average geographical scope that the first level of an executive decision-making body will have to care for thus allowing for greater focus and better tailored management Coordination with local authorities and the role of citizens will also be reinforced with this strategy The Portuguese perspective of integration of care through a single LHU system meets a concept of integration that focuses on the patient through two distinct models: structural integration that comprises the ownership of infrastructures and the services offered therein through an articulated supply chain, and functional integration that enhances effective service coordination (25) Nunes (40) conducted a SWOT analysis of this specified reform, while also considering other changes taking place in the overall healthcare system, identified six strengths and essential points of this measure (Table 1) and concluded that the model is promising The key opportunities in the integration of healthcare services lie in strengthening primary care By focusing on people-centered care and empowering local authorities healthcare systems can enhance effectiveness and adaptability significant challenges such as the increasing health needs of the population and resistance to organizational change must be addressed to ensure successful integration efforts The implementation of these measures requires a parallel process of close follow-up The NHS EB is providing close support and townhall meetings with all leaders of the institutions of the NHS to share the current challenges and best practices during this change process A thorough and open analysis of the clinical and financial impacts of this form of organization is essential even if based on a careful assessment of the pros and cons and international scientific evidence requires an independent assessment with a view to continuous improvement of the ongoing transformation An independent public university will be conducting the evaluation process with benchmarking The literature lacks reports of vertical integration as extensive as Portugal’s NHS-wide approach Partial experiments show positive effects on efficiency it is important to consider the risks inherent in the model and ensure adequate support in terms of promoting the real integration of care which includes the participation of both the government and society Portugal is deciding to take this step forward supporting the mobilization and engagement of institutions and communities looking to the goal of achieving better health for all The original contributions presented in the study are included in the article/supplementary material further inquiries can be directed to the corresponding author JoS: Writing – review & editing AM: Writing – review & editing The author(s) declare financial support was received for the research Imperial College London kindly agreed to fund the open access fees for this paper We thank Imperial College London for funding the open access fees of this paper FG-d-S and RM serve on the Management Board of the Portuguese National Health Service Executive Board and RV serve as advisors to the Portuguese National Health Service Executive Board AD is Chair of the Health Security initiative at Flagship Pioneering UK Ltd FA is the Executive Director of the Portuguese National Health Service Executive Board The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher 1. 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Volume 3 - 2023 | https://doi.org/10.3389/frhs.2023.1352322 This article is part of the Research TopicInnovations in Quality of CareView all 7 articles Editorial on the Research TopicInnovations in quality of care The European Programme of Work 2020–2025, “United Action for Better Health in Europe”, and the United Nations' Sustainable Development Goals place an emphasis on achieving universal health coverage by ensuring that health services are of sufficient quality to be safe, effective, and accessible (4, 5). This involves meticulous planning, execution, and continuous evaluation (6) the World Health Organization's Quality of Care and Patient Safety Office in Athens hosted the inaugural “Meeting of the Minds” Conference on quality of care in December 2021 This conference aimed to outline a roadmap for the implementation of key actions in five thematic areas: (1) Innovation and best practices in quality of care and patient safety; (2) Fostering partnerships and collaborative networks for quality of care; (3) Sharing Member States' healthcare responses during the COVID-19 pandemic; (4) Prioritizing the patient perspective and shared decision-making in healthcare; (5) Advancing the development and evaluation of evidence-based national quality of care plans Such case studies formed the basis of the Frontiers in Health Services Research Topic “Innovations in Quality of Care” The aim was to invite authors to submit recent research and policy work related to innovative approaches to solving local The work by Benning et al. was conducted in Germany and its aim was to determine the prevalence of core Ambulatory Care Sensitive Conditions (core-ACSCs) among emergency department patients in an academic tertiary hospital and to evaluate the urgency of these conditions as indicated by triage levels the study aimed to examine factors influencing these admissions to gain an understanding of potentially preventable visits to the emergency department (ED) This study reveals that while core-ACSCs significantly contribute to ED patient volume they are not the primary factors driving ED crowding 65.2% of the patients who presented with what were later confirmed to be core-ACSCs necessitated urgent care This underscores the role of efficient ambulatory care in preventing ED presentations Although this warrants further investigation such findings suggest that these core-ACSCs could be viewed as potentially avoidable ED presentations The manuscript by Wang and Liu focused on understanding the diverse demands of older adults in China for home- and community-based integrated care The findings highlight the complexity of the care needs of the elderly and underscore the importance of designing varied and tailored integrated care sub-models to effectively meet these diverse requirements Sener et al. proposed an integrated approach that combines technology-enabled care with continuous monitoring of hospital capacity to improve care and manage capacity during outbreaks They emphasized the importance of including patients at high risk for severe infectious diseases who cannot be hospitalized By identifying patients at risk for future deterioration based on evidence-based risk factors this approach allows prioritization for remote care programs taking into account real-time hospital capacity With the availability of home-based antiviral and antibacterial treatments They regulate the flow of patients to hospitals during capacity shortages provide safe and effective treatment at home and help improve patient safety and quality of care particularly by reducing hospital length of stay The study by You et al. focused on identifying factors that influence depression in older adults living at home and activities of daily living (ADL) significantly influenced geriatric depression Older adults in the 60–69 years age range had the highest incidence of depression due to changes in physical condition and social roles The study also found that self-care significantly reduced depression Higher ADL scores were associated with a lower incidence of depression This study underscores the importance of improving the quality of care by fostering self-care and mutual aid among older adults to reduce depression and improve their quality of life The manuscript by Chibi et al. provided a comprehensive review of various digital and device-based innovations categorizing them as digital platform-based and various devices like drones and rapid diagnostic tools The findings reveal a technological shift towards the use of big data and Artificial Intelligence suggesting potential improvements in HIV program delivery The article advocates for African countries to leverage these technologies for enhanced healthcare delivery and policy infrastructure in adopting these innovations The study underscores the critical role of technological developments in advancing HIV services and calls for strategic implementation in African contexts to optimize health outcomes Finally, the study protocol by Hynes et al. outlines a comprehensive multi-methods approach to understanding care coordination for veterans with complex care needs within the Veterans Health Administration The protocol is structured around three primary aims: (1) to examine the relationship between care coordination processes and health outcomes; (2) to assess veterans’ perspectives on care integration and patient-centeredness; and (3) to understand providers' perceptions of care coordination tools and processes The study's novel approach lies in its comprehensive examination of care coordination from multiple perspectives—patients The protocol serves as a blueprint for future research in similar complex healthcare systems emphasizing the need for multidimensional assessment and evidence-based care coordination strategies As advancements redefine the healthcare landscape tailored strategies that can ensure quality We aim to inspire researchers to rigorously engage with the topic of innovation in healthcare quality AD: Writing – review & editing HA: Writing – review & editing FG-d-S: Writing – review & editing NA-M: Writing – review & editing All authors would like to express their gratitude to Válter R from the WHO Athens Quality of Care and Patient Safety Office as well to Joseph Davids from Imperial College London for their contribution to this editorial The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest COVID-19 has inspired global healthcare innovation PubMed Abstract | Crossref Full Text | Google Scholar and innovation in healthcare during the COVID-19 pandemic: the challenge of translating knowledge infrastructures to public needs OECD policy responses to Coronavirus (COVID-19) 2020–2025: United action for Better Health Copenhagen: WHO Regional Office for Europe (2021) 5. United Nations. Sustainable Development Goals. Available at: https://sdgs.un.org/goals (Accessed November 26 High-quality health systems in the sustainable development goals era: time for a revolution Goiana-da-Silva F and Azzopardi-Muscat N (2024) Editorial: Innovations in quality of care Received: 7 December 2023; Accepted: 13 December 2023;Published: 5 January 2024 Edited and Reviewed by: Joris Van De Klundert © 2024 Breda, Darzi, Ashrafian, Goiana-da-Silva and Azzopardi-Muscat. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) *Correspondence: João Breda cm9kcmlndWVzZGFzaWx2YWJyZWRAd2hvLmludA== Metrics details Various vector-borne pathogens (VBPs) affect dogs worldwide with their diversity and force of infection being usually higher in the tropics Cross-sectional studies have been conducted to investigate the prevalence of VBPs in dogs but data from longitudinal studies are scarce we assessed the prevalence and the year-crude incidence (YCI) of Leishmania spp and other VBPs in privately-owned dogs from two geographical regions of Brazil A total of 823 dogs were initially screened for Leishmania spp by both serology and polymerase chain reaction (PCR) Pernambuco) were randomly selected for the longitudinal study These dogs were tested for various VBPs at baseline 131 (15.9%) were positive for Leishmania spp Out of the 307 dogs enrolled in the longitudinal study 120 (39.1%) were lost for different reasons (e.g the baseline prevalence and YCI were as follows: 16.5% and 7.1% for Anaplasma spp.; 81.6% and 100% for Babesia spp.; 0% and 1.3% (only one faint positive) for Dirofilaria immitis; 37.9% and 22.9% for Ehrlichia spp.; 19.5% and 43.8% for Leishmania spp the baseline prevalence and YCI were as follows: 45.1% and 38.3% for Anaplasma spp.; 79.9% and 96.0% for Babesia spp.; 36.3% and 39.8% for D immitis; 64.7% and 58.5% for Ehrlichia spp.; 14.7% and 19.6% for Leishmania spp Anti-Borrelia burgdorferi antibodies were not detected in any of the samples tested herein infection was significantly higher in São Joaquim de Bicas We confirmed a high prevalence and YCI of various VBPs among privately-owned dogs in two geographical regions of Brazil Our data also indicate that the risk of infection varies significantly for individual VBPs and between the regions which may be related to several factors that are still poorly understood Prevalence data cannot per se be used to infer incidence also considering that seroconversion may take months to occur and that antibodies produced against certain pathogens may last for months we estimated the year-crude incidence (YCI) of infection by Leishmania spp based on data gathered from two cohorts of privately-owned dogs followed up for 1 year and whose new infections were diagnosed by serological and molecular tests infections by other VBPs were also investigated This study was conducted from September 2015 to November 2016 The first site was the municipality of Goiana (7°33′39″S Goiana has a tropical savanna climate with dry-summer characteristics which corresponds to the Köppen climate classification categories “Aw” and “As” The mean annual temperature and precipitation are 24.9 °C and 1924 mm The mean monthly temperature ranges from 23.3 °C to 26 °C whereas the mean monthly precipitation ranges from 46 mm to 307 mm The second site was the municipality of São Joaquim de Bicas (20°02′56″S São Joaquim de Bicas has a humid subtropical climate with dry-winter characteristics which corresponds to the Köppen climate classification category “Cwa” The mean annual temperature and precipitation are 21.5 °C and 1348 mm The mean monthly temperature ranges from 18.3 °C to 23.9 °C whereas the mean monthly precipitation ranges from 10 mm to 287 mm The study population included initially 823 privately-owned dogs which were screened for anti-Leishmania spp Part (n = 632) of these dogs was also tested for Leishmania minicircle kinetoplast DNA (kDNA) by real-time PCR From the negatives to both serology and PCR and complying with some inclusion criteria (i.e untreated with ectoparasiticides with known efficacy against VBPs availability of written owner consent form) 307 (168 males and 139 females) dogs were randomly selected for the longitudinal study with age ranging from 2 months to 13 years (average = 2.7 years) Except for 76 dogs whose owners reported (at least once) the use of ectoparasiticides (39 in Goiana all dogs were not treated to prevent ectoparasite infestations throughout the entire observation period a 5 ml blood sample was collected from each dog Approximately 3 ml of blood were added to BD SST™ gel tubes and the remaining blood (2 ml) were collected in EDTA (purple cap) collection tubes BD SST™ gel tubes were centrifuged at 2000× g for 10 min for serum separation Aliquots of sera were then immediately tested as described below Remaining serum samples and EDTA-blood samples were frozen at − 20 °C dogs were tested for antibodies to Leishmania spp using at least one of the following tests: ELISA/S7® (Biogene) All dogs randomly selected for the longitudinal study had to be negative by the SNAP® Leishmania Test (and also by PCR) which was the one used to retest the dogs after 8 and 12 months All dogs included in the longitudinal study were also tested (at baseline after 8 and 12 months) by a rapid ELISA (SNAP® 4Dx Plus Test USA) that detected antibodies to Anaplasma spp dogs were tested by an indirect immunofluorescence (IFA) that detected antibodies to Babesia spp All serological tests were performed using serum samples and according to the manufacturer’s instructions EDTA-treated blood samples collected from dogs were subjected to DNA extraction using a commercial kit (PureLink® Mini Kit according to the manufacturer’s instructions The quantity and purity of the extracted DNA were assessed using a NanoDrop 2000c Spectrophotometer (Thermo Fisher Scientific USA) and samples were then stored at − 20 °C infantum genomic DNA (MHOM/BR/76/M4192) at different concentrations (1 ng A master mix with no DNA was used as no template control (NTC) Real-time PCR reactions were performed using QuantStudio® 5 Real-Time PCR system (Applied Biosystems USA) and results were analysed using QuantStudio Design and Analysis Software v1.4 (Applied Biosystems Each reaction contained 8.5 μl of DNA-free water 12.5 μl of GoTaq® Colorless Master Mix (Promega 1.0 μl of each primer at a concentration of 25 pmol/μl and 2 μl of DNA sample Thermal cycling conditions were as follows: initial denaturation at 95 °C for 2 min and a final extension step at 72 °C for 5 min DNA extracted from the blood of a dog infected by B vogeli was used as positive control and a master mix with no DNA as NTC Each reaction contained 7.5 μl of DNA-free water 1.5 μl of each primer at a concentration of 10 pmol/μl and 2 μl of DNA sample Thermal cycling conditions were as follows: denaturation at 95 °C for 1 min and a final extension step at 72 °C for 7 min DNA extracted from the blood of a dog infected by A platys was used as positive control and a master mix with no DNA as NTC 1.5 μl of each primer at a concentration of 10 pmol/μl 12.5 μl GoTaq® Colorless Master Mix (Promega USA) and 2 μl of the sample DNA to be tested Thermal cycling conditions were as follows: denaturation at 95 °C for 30 s with a final extension step at 72 °C for 1 min DNA extracted from the blood of a dog infected by E canis was used as positive control and a master mix with no DNA as NTC All conventional PCR assays were run on a Veriti® 96-Well Thermal Cycler (Applied Biosystems USA) and amplicons were analysed by 1.5% agarose gel electrophoresis and visualized in ultraviolet light Baseline prevalence was calculated for each of the two study locations considering dogs positive to one or more tests was calculated using data from all dogs initially screened whereas for other pathogens it was calculated using data from dogs included in the longitudinal study Exact 95% confidence intervals (95% CI) were calculated for each baseline prevalence YCI was expressed as percentage and calculated considering the number of dogs positive at the interim and/or at the final follow-up using the following formula: number of positive dogs/(number of negative dogs at baseline − number of dogs lost to follow up) × 100 “dogs lost to follow up” were those tested at baseline but removed from the study before the interim follow-up (i.e we used the last observation carried forward (LOCF) method so data from dogs tested at the interim follow-up but removed before the final follow-up were included in the calculations dogs positive at the interim follow-up and eventually negative at the final follow-up were considered as positive The differences in baseline prevalence and YCI for each pathogen between dogs from São Joaquim de Bicas and Goiana were tested using Chi-square test, with a P < 0.05 considered statistically significant. Calculations and statistical analyses were performed using GraphPad QuickCalcs (http://www.graphpad.com/quickcalcs/) and BioEstat version 5.3 (Instituto de Desenvolvimento Sustentável Mamirauá While the illiteracy rate is generally higher in Goiana as compared to São Joaquim de Bicas a detailed analysis of individual dog owner education level would be necessary to assess whether this could be a main driver for the higher prevalence and YCI in São Joaquim de Bicas Out of the 307 privately-owned dogs enrolled in the longitudinal study 120 (39.1%) were lost during the 1-year observation period for different reasons (e.g The losses were higher in Goiana (n = 87; 42.7%) as compared to São Joaquim de Bicas (n = 33; 32.0%) including higher exposure to sand fly vectors which may be ultimately related to poor housing conditions our results may suggest that the tick population present in Goiana may be more capable of transmitting E canis as compared to the population of São Joaquim de Bicas this could also be related to seasonal patterns to tick infestations on dogs in these municipalities further studies are needed to confirm the presence and significance (if any) of borreliosis in dogs from this part of the world Longitudinal studies on the very same population of dogs are challenging to conduct especially with privately-owned dogs that are untreated against ectoparasites One of the major challenges is the high proportion of dogs lost to follow-up data generated herein will be useful for future studies and analyses perhaps also for different pathogens not considered herein This study confirms high prevalence and YCI of various VBPs in dogs in two geographical regions of Brazil Our data also indicate that the risk of infection varies significantly for individual pathogens and between the regions which may be related to several biotic (e.g climate and socioeconomic status of dog owners) and abiotic (e.g vector competence and capacity of different tick populations) factors that are still poorly understood YCI may be somewhat underestimated in this study considering the ectoparasitic treatments that some dogs received and considering that the LOCF method for missing data at the final follow-up was applied to all dogs concerned including dogs that were negative at the interim Such dogs might have become positive until the final follow-up but were considered to be negative within the analyses the impact is expected to be low as only limited numbers of dogs were concerned The data supporting the conclusions of this article are included within the article and its additional files Raw data can be shared with other researchers upon specific request Conselho Nacional de Desenvolvimento Científico e Tecnológico Managing canine vector-borne diseases of zoonotic concern: part one Managing canine vector-borne diseases of zoonotic concern: part two haematological and biochemical findings in young dogs naturally infected by vector-borne pathogens Are vector-borne pathogen co-infections complicating the clinical presentation in dogs Best practices for preventing vector-borne diseases in dogs and humans Toward the formation of a Companion Animal Parasite Council for the Tropics (CAPCT) and humans in Brazil: opening the black box Ecology of Lutzomyia longipalpis in an area of visceral leishmaniasis transmission in north-eastern Brazil Vector-borne parasitic zoonoses: emerging scenarios and new perspectives Human intraocular filariasis caused by Dirofilaria sp The burden of neglected tropical diseases in Brazil 1990–2016: a subnational analysis from the Global Burden of Disease Study 2016 The epidemiology of canine leishmaniasis: transmission rates estimated from a cohort study in Amazonian Brazil Cross-sectional and longitudinal epidemiologic surveys of human and canine Leishmania infantum visceral infections in an endemic rural area of southeast Brazil (Pancas Serologic prevalence of Dirofilaria immitis and Borrelia burgdorferi infections in Brazil Frequency of antibodies anti-Ehrlichia canis Borrelia burgdorferi and Dirofilaria immitis antigens in dogs from microrregion Ilhéus-Itabuna A serological and molecular survey of Babesia vogeli Exposure to vector-borne pathogens in privately owned dogs living in different socioeconomic settings in Brazil infection in rural dogs from remote indigenous villages in north-eastern Brazil Advantages of real-time PCR assay for diagnosis and monitoring of canine leishmaniosis sensitive and low-cost real-time PCR assay for the detection of Leishmania infantum and Leishmania braziliensis kinetoplast DNA in canine blood samples Coinfection with multiple tick-borne pathogens in a walker hound kennel in North Carolina Serological and molecular prevalence of Borrelia burgdorferi and Ehrlichia species in dogs from Minnesota Prevention of endemic canine vector-borne diseases using imidacloprid 10% and permethrin 50% in young dogs: a longitudinal field study Preventing zoonotic canine leishmaniasis in northeastern Brazil: pet attachment and adoption of community Leishmania prevention Instituto Brasileiro de Geografia e Estatística (IBGE). Cidades. http://www.cidades.ibge.gov.br/xtras/home.php Updated canine infection rates for Dirofilaria immitis in areas of Brazil previously identified as having a high incidence of heartworm-infected dogs Heat treatment and false-positive heartworm antigen testing in ex vivo parasites and dogs naturally infected by Dirofilaria repens and Angiostrongylus vasorum Molecular survey and genetic characterization of tick-borne pathogens in dogs in metropolitan Recife (north-eastern Brazil) Molecular epidemiology of the emerging zoonosis agent Anaplasma phagocytophilum (Foggie First report of Ehrlichia ewingii detected by molecular investigation in dogs from Brazil Babesia gibsoni genotype Asia in dogs from Brazil Prevention of canine leishmaniosis in a hyper-endemic area using a combination of 10% imidacloprid/4.5% flumethrin Efficacy of an imidacloprid/flumethrin collar against fleas Comparative evaluation of the vector competence of four South American populations of the Rhipicephalus sanguineus group for the bacterium Ehrlichia canis the agent of canine monocytic ehrlichiosis A review on the occurrence of companion vector-borne diseases in pet animals in Latin America Download references We thank the Secretaria Estadual de Saúde de Pernambuco and Secretaria Municipal de Saúde de Goiana for their logistic support during field activities Thanks also due to all veterinarians and students involved in the field activities and Gabriela Dantas Torres Guimarães for data quality control Publication of this paper has been sponsored by Bayer Animal Health in the framework of the 15th CVBD® World Forum Symposium This study was sponsored by Bayer Animal Health and Idexx Laboratories provided the SNAP 4Dx tests FDT is the recipient of a research fellowship from the Conselho Nacional de Desenvolvimento Científico e Tecnológico CNPq (CNPq; 313118/2018-3) Joanna Lúcia de Almeida Alexandre & Yury Yzabella da Silva Centro Universitário do Vale do Ipojuca (UNIFAVIP/Wyden) Pontifical Catholic University of Minas Gerais Guilherme Ribeiro Valle & Vitor Márcio Ribeiro Matthias Pollmeier & Gertraut Altreuther YYS and LGS performed the diagnostic tests FDT performed the statistical analyses and wrote the first draft MP and GA provided scientific advice for the study and reviewed the manuscript All authors read and approved the final manuscript The Committee on Ethics in the Use of Animals (CEUA project number: 66/2014) of the Aggeu Magalhães Institute (Fiocruz) approved the procedures used in this study Dog owners signed a consent form before the inclusion of their animals in this study KD and MP are employees of Bayer Animal Health GmbH FDT and DO are members of the CVBD World Forum whose activities are sponsored by Bayer Animal Health This study and the publication of this article were sponsored by Bayer Animal Health IDEXX Laboratories provided the SNAP 4Dx tests Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Total number of dogs tested by serology and PCR for different pathogens at each time point (baseline in Goiana (Pernambuco) and São Joaquim de Bicas (Minas Gerais) Numbers are expressed as “positive/total (positivity)” unless otherwise stated in a credit line to the data Download citation DOI: https://doi.org/10.1186/s13071-020-04056-8 Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. 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Read our policy By and 2015-07-03T12:59:24+01:00 Fiat Chrysler has increased investment in Brazil opening a plant in the north-east even as the market declines Industrial director Mauro Pino talks about logistics strategies for managing both near and long distance supply chains which has a market share of around 20% in Latin America has opened its new plant in north-east Brazil at a time when vehicle sales in the country are stalling and fiscal tightening is being implemented have recently imposed temporary shutdowns to reduce climbing vehicle stocks “Brazil’s car market is undergoing a period of sales retraction We believe the first signs of improvement should appear late this year or early next year,” says Mauro Pino who became FCA’s industrial director for Latin America last year Pino had recently been head of manufacturing in North America.  FCA has invested 7 billion reais ($2.2 billion) at its recently opened plant in Goiana in Pernambuco 3 billion reais were invested in its Jeep assembly plant which can already produce 800,000 vehicles including a new three-storey paintshop to improve customisation.  the plant in Pernambuco has an installed production capacity of 250,000 vehicles per year It can produce up to three different models simultaneously and is currently building the Jeep Renegade for export across Latin America.  Designing an effective supply chain for Pernambuco was important for FCA The on-site supplier park covers an area of 270,000 sq.m and houses 16 suppliers that produce 17 component product lines at a dozen different factories These suppliers account for around 40% of the Jeep Renegade’s content etc.) and complex systems such as instrument dashboards engine cooling and air conditioning.  Other components from elsewhere in Pernambuco Minas Gerais and other states bring the Jeep’s local content to 80%.  some of these ‘local’ parts arrive from thousands of kilometres away FCA has adopted a crossdock concept to centralise the delivery of components Crossdocks are installed in Minas Gerais and São Paulo Regional supplies are collected for the crossdocks and repacked into daily Material arrives to a 54,000 sq.m distribution centre and are sequenced for delivery to the assembly line.  Pino explains that the parts needed for production at the plant will be called using a pull system Given the average distance between Pernambuco and consumer markets in São Paulo FCA has designed an outbound system that balances truck movements between its two plants Trucks out of the Betim plant carry northbound vehicles and return south with Jeep products from Pernambuco “This requires the synchronisation of shipments to the south at the same rate of movement as trucks arriving with products from Betim,” says Pino cancelling out some 42m litres of diesel and 101,000 tonnes of carbon emissions To further ensure management of vehicle logistics FCA built a yard for 5,900 vehicles at the new plant Vehicle monitoring will be done through a stock management and parking system Following the same pace of production and sales the Pernambuco plant’s production flows will be managed daily FCA estimates that 100-120 outbound trucks a day will leave Pernambuco is a strategic element in terms of future imports of parts along with the export of cars produced in the plant the port was one of the reasons FCA chose the region for the Jeep plant The carmaker’s vehicle imports currently pass through the ports of Rio de Janeiro and Santos before going to three cities in Minas Gerais to be adapted for the national market Fiat Chrysler may use Suape to import vehicles for northern Brazilian cities It could also be a potential gateway for Jeeps to neighbouring countries Click here to read about the state of Brazil's automotive logistics industry – maintaining traction through efficiency Site powered by Webvision Cloud soldiers surround a squalid whitewashed house sandwiched between several others on a dusty cobbled street where an elderly woman has locked herself in decaying food and grimy pots and pans are piled knee high throughout the house The cracked walls are teaming with bacteria Walking through the town's poor outlying districts, where many of its 78,000 residents live in similar destitution, it is easy to see why Goiana, in Pernambuco state, is desperately losing the battle with Zika.  Outside the woman's home, a loudspeaker truck blasts out orders: 'Come out of your home, Mrs Jacienta, peacefully'.  Anxious neighbours watch from a distance as the tense standoff unfolds, until eventually an old lady emerges from inside and shuffles nervously down her garden path.  There are shouts and applause as, after an intense discussion, she removes the padlock from her front gate and the soldiers file inside. If she had not, they would have forced their way in, as they have in several other homes where they suspect the mosquitos which transmit the virus to be.  In Mrs Jacienta's overground garden there is standing water - including buckets, bottles and a swimming pool - which could be harbouring the mosquitos' larvae.  The estimated infection rate in her hometown of Goiana - dubbed 'Zika Town' - is higher than anywhere in the country. Already more half the town's population - at least 40,000 people - are already believed to have contracted one of the diseases spread by the mosquito - Zika, dengue and chikungunya. Meanwhile, up to 500 townsfolk are arriving at the town's stretched health clinics and A&E department every day, complaining of Zika-like symptoms. According to new, so far unreported figures, 27 babies have so far been born with microcephaly, the 'shrunken head' syndrome linked to the infection. And at 6.3 per 1,000 live births, it is the highest rate of microcephaly incidence anywhere in the world. Another 12 pregnant women believed to be carrying babies with microcephaly will give birth in the coming months. Before the epidemic, not one single case of microcephaly had ever been registered in the region. It means that the so far unknown country town is now the epicentre of the global Zika epidemic which is causing concern around the world. MailOnline visited Goiana, a small but bustling market town near the Atlantic coast in the north of the state of Pernambuco, and found a community brought to its knees by the virus, council workers stretched to the limit and a health system on the brink of collapse. On the day we arrived, even the town's mayor, Frederico Gadelha, was thought to have been struck down by Zika. From his bed, he said: 'I feel terrible. My whole body is hurting so much, I'm itching all over and I'm so weak I can't stand up on my feet. 'My town is in chaos. This is an emergency, the worst this town has ever experienced. We will only beat it if the whole community comes together to do their part.' But Daniele Uchoa, director of Goiana's local health authority, said she fears the situation is about to get much worse. She said: 'I don't know why Zika chose to hit our little town the hardest. Our health system was not prepared for this. 'We are expecting rains in March and April, and we are afraid what this might mean for us. 'We know that the Zika mosquito has mutated, and learned to survive in new habitats, including dirty water. If things get worse, the health service won't be able to cope. Nobody knows how bad it might get. 'We are all living in a state of daily anguish. I truly hope we can overcome it, but I know it will not be easy.' Goiana was the first municipality in Pernambuco state to declare an 'emergency situation' due to Zika, in November last year, as the town started to be overwhelmed by new cases of the disease. That was before most of the babies of women who had been infected by Zika began to be born - many with the 'shrunken head' condition which is linked to the disease. The municipality has embarked on campaigns to educate residents, including distributing leaflets, door-to-door visits by community health workers and sometimes the use of the army to force entry into properties where mosquito breeding grounds are suspected. The most recent action, on Saturday morning, came after the reclusive woman had repeatedly refused to allow inspectors into her home, following complaints by local residents and a spike of Zika cases on the street. But with latest figures showing infections higher than at any time, Goiana is still losing the battle against the disease. Open sewers flow along both sides of most residential streets, while standing water collecting in puddles, rubbish-strewn streams and broken drains provide ideal conditions for mosquitos to thrive. With many families living in squalid conditions, insect repellent and mosquitos nets are luxuries few can afford, and with water in short supply, residents often store water when it comes, which often become breeding sites within their own homes. In fact it is hard to find a single household which has not been laid low by one of the viruses caused by the dreaded aedes aegypti mosquito. At the end of a dirt alley in the impoverished district of Nova Goiana, we find a couple who have perhaps suffered the most at the hands of Goiana's terrifying Zika epidemic. Silvana Bernardo de Silva, 31, dissolves in tears and has to be held by a friend as she remembers her baby daughter Luiza Vitoria, who died last month, 37 days after she was born with microcephaly. The mother had been diagnosed with dengue, now believed to be Zika, when she was ten months pregnant. At five months, she and husband Antonio were told that the baby's brain was deformed and at seven months, another ultrasound scan revealed she had microcephaly. Silvana says: 'I didn't really care what the doctor was saying, because I knew I would love and care for her no matter what. I was ready to face whatever problem there might be.' After baby Luiza Vitoria was delivered by C-Section on December 8, Silvana was told that her daughter would die as soon as doctors cut her umbilical cord. Silvana remembers: 'For me, she was beautiful, perfect. I couldn't see anything wrong with her. 'They cut the cord and then told me she'd gone, and asked if I wanted to hold her one last time. They put my dead baby on my chest and I held her close. But something inside me didn't believe that she had really died.' Husband Antonio, 38, a driver, recalls: 'They called me in to say goodbye, but as I came close I saw bubbles coming from my baby's mouth. 'I shouted, "my girl's alive" and the doctors came, but they said I was just seeing the last beats of her little heart. They said there was nothing that we could do to bring her back.' Twenty minutes later, however, little Luiza Vitoria still had not passed away. Silvana says: 'The doctors said they would give her two hours to fight alone. They took her away and laid her in a cot, thinking she wouldn't make it. But two hours later she was still alive. 'So they put her in an incubator. Nobody could believe why she hadn't died, they kept saying that her brain was incompatible with life, that it was too damaged for her to survive. But she fought hard to stay alive.' The couple were allowed to bring their daughter home three times over the following month, including Christmas and New Year. Silvana, who earns a minimum salary of £120 a month as a housemaid, said: 'I never saw anything wrong with her. She would take my hand, smile and giggle. I would talk with her all the time and she would look into my eyes, as if she knew what I was saying. 'She would always want to suckle my breast, but the doctors always told me not to let her try. I always believed that she would make it and come home for good. 'All the time the doctors kept telling me that she was going to die at any moment, but I never believed them.' Silvana, who also has a seven-year-old daughter, said she was holding her hand when, on January 14 after her baby's condition worsened, she finally lost her. Sobbing, she remembers: 'I still can't believe she's gone. I cry all the time. I still wake up and see her in my room, I hear her crying, I smell her around the house. I miss her so much. 'She'll always be with me. And I'll always thank God for having put her into our lives and allowed her to be with us for the time she did.' Dad Antonio said: 'She was our little warrior. She fought right until the end and she'll never be forgotten. 'She was put into our lives for a reason. She taught us so much and brought us closer. I used to drink a lot, but after she came I completely stopped, she made such a difference in my life. 'I'm not going to remember any of the bad things, I've left them all in the hospital. Now I'll just remember the good, the beautiful.' Maria Lucia, the community health agent who is responsible for the Nova Goiana district, which is home to 190 families, said she fears there could soon be other parents having to go through the same nightmare. She says: 'I've never seen so many people getting ill at once. In every other house you'll find one, two or even three people with Zika. The elderly, small children, pregnant women, no-one is being spared.' And she claims the situation need not have got out of hand if authorities had acted earlier.  She said: 'There is no basic sanitation here, the sewage flows right down the the street in the open air. We've had year after year of dengue outbreaks, but no action was ever taken to prevent them. 'I've complained so many times but nobody does anything. Now everybody's getting ill, and pregnant women here are absolutely terrified.' At the town's Belarmino Correio general hospital, patients complaining of symptoms of Zika virus pack the A&E reception. One pregnant teenager sobs as she awaits her turn to be examined by a triage nurse. Inside, a clearly flustered Dr Bruno Brito, 29, one of just two doctors on shift, instructs staff to prioritise patients who are elderly, pregnant, or who have an underlying health condition. Already today, two pregnant women have arrived with suspected Zika, and sent to the hospital's maternity unit for tests. Dr Brito told MailOnline: 'Everyone will get seen, but some might have to wait for many hours. It's chaotic. 'We're seeing more than double the number of patients as normal. Ninety percent of them are experiencing symptoms of Zika.' He said that in one 11-hour shift last week he and another doctor saw He said: 'It's exhausting, which is worrying because I know I'm dealing with people's lives and I have to be alert. With just two doctors at any one time we are stretched to the limit. 'What if an emergency arrives and I'm too tired from seeing so many patients with Zika to safely make the right decision?' Nurse Ana Claudia Albuquerque, who is also the council's Primary Health Care director, admits: 'The hospital is descending into chaos. We have run out of places to put patients and the workload is too much for for number of staff. 'On my last shift a shift doctor got ill because he was working so hard.  'This epidemic caught us all by surprise, we never expected that so many people would get infected. But the worst is, 2016 is already surpassing our worst expectations.' She explains that most patients end up being recorded as having dengue, because the state health authority still hasn't provided the serology test kits to diagnose Zika. Just last month, 1,463 cases of 'dengue' were recorded in the town. Among patients suffering Zika-like symptoms, tests are only ordered on pregnant women, with samples sent off for testing at a laboratory in state capital Recife. Even so, since the beginning of the year 153 patients from within the health authority have been investigated for Zika infection, all of whom are still awaiting their results. Ana Claudia adds: 'We're talking about a whole generation of children being born, who will need specialist care for the rest of their lives. For this number of children with microcephaly the town will need a new hospital just to support them. 'Even after Zika has gone, Goiana will be struggling to cope with the damage it has done for decades to come.' On the other side of town, in the Bom Tempo district, yet another mother is coming to terms with Rayane Gomes, 19, only discovered that her son Alessandro had microcephaly after he was born, on October 22 last year. She says: 'I remember looking at him, then looking at another mother's baby, and seeing that mine was different. 'But staff at the hospital didn't tell me, they said I had to stay in hospital for three days for a specialist to arrive. Even then, nobody told me what was wrong, they just told me to book an appointment in Recife.' At the Oswaldo Cruz University Hospital in Recife, Rayane was told her baby boy had the condition. She recalls: 'I started to cry and someone had to come and comfort me. They told me there's no cure but there is treatment. 'Even now, I cry every day. I can't bare to think that he is in pain or will have to suffer for the rest of his life.' Rayane, who also has a two-year-old daughter, is still waiting for tests to confirm her baby's brain damage - but she says she already knows Alessandro has problems. She says: 'Sometimes he shakes, or sometimes goes all limp. And I know there are problems with his eyes. Often when he wakes up he can't open them, especially in the light. 'He rolls his eyes and shakes his head, and he gets distressed, as if he's in pain. For a mother that's torture, I just want to make things better but I know I can't. 'He cries for hours on end and suffers a lot of headaches. I have to have a lot of patience to care for him 24 hours a day.  'And it's been difficult on us financially, especially because once a month we have to take him to Recife to see a specialist. 'It makes me angry to think that a mosquito has caused all this suffering. There are other pregnant mothers near here who have contracted Zika and I pray to God they don't have to go through the same as me. 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Inside the world's most Zika-infected townCommenting on this article has endedNewest{{#isModerationStatus}}{{moderationStatus}} Official ‘covers-off’ will be at the Los Angeles Auto Show in November First-up we must say the styling is a great turnaround from t + 3 PhotosAll-New Jeep Compass Revealed In BrazilJeep has released these images of the all-new Compass which has commenced production in Goiana Official ‘covers-off’ will be at the Los Angeles Auto Show in November First-up we must say the styling is a great turnaround from the current dowdy look – the newcomer integrating a handsome and purposeful front-end borrowed from the up-scale Jeep Grand Cherokee with an all-new rear-end which possibly shows some cues to the Renegade in the C-pillars with the shutline for the rear doors extending to the tailgate. Copyright Drive.com.au 2025ABN: 84 116 608 158 all prices are shown as Manufacturer's Recommended List Price (MRLP) inclusive of GST