{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T10:12:43Z","timestamp":1788862363799,"version":"build-2803163510"},"reference-count":54,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T00:00:00Z","timestamp":1788825600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Epidemiologia"],"abstract":"<jats:p>Background: Community-acquired pneumonia (CAP) remains a leading cause of morbidity and mortality worldwide and a major driver of hospital admissions. Older adults are disproportionately affected, owing to immune senescence and a higher prevalence of chronic comorbidities. This study examined two decades (2000\u20132019) of adult hospital admissions for CAP in mainland Portugal. Methods: We analyzed adult CAP hospitalizations between 2000 and 2019 from the Portuguese Mainland Hospital Diagnosis National Database. We assessed all hospitalizations attributable to CAP over the 20 years, stratified by age group, and examined seasonal variation. Trends in hospital length of stay and in-hospital case fatality were evaluated. Results: Between 2000 and 2019, the adult CAP hospitalization rate in Portugal rose from 3.61 to 5.28 per 1000 persons-year. This was fostered by patients older than 80 years, who grew from 30.4% to 53.1% of CAP admissions. The mean age increased over time, from 70.1 \u00b1 17.0 years to 77.7 \u00b1 14.1 years. Hospitalization episodes of patients older than 85 years admitted for CAP increased fourfold. CAP-associated case fatality increased slightly, driven by patients older than 80 years. A modest decline was noted from 2016 to 2019 (from 23.1% to 21.8%). This was strongly correlated with mean age. Invasive mechanical ventilation was offered in a growing number of hospitalization episodes of CAP (from 3.1% in 2000 to 7.5% in 2019) but with significant age imbalance. Admissions peaked in January, whereas case fatality was highest during the summer months. Conclusions: These findings underscore the growing burden of CAP on healthcare systems, driven by an aging population and rising life expectancy. This has implications for both resource allocation and preventive strategies.<\/jats:p>","DOI":"10.3390\/epidemiologia7050125","type":"journal-article","created":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T09:02:24Z","timestamp":1788858144000},"page":"125","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Trends in Hospitalization, Case Fatality, and Mortality for Community-Acquired Pneumonia in Portugal over 20 Years"],"prefix":"10.3390","volume":"7","author":[{"given":"Rita","family":"Oliveira","sequence":"first","affiliation":[{"name":"Chest Department, Unidade Local de Sa\u00fade Santa Maria, 1769-001 Lisboa, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Diogo","family":"Batista","sequence":"additional","affiliation":[{"name":"Chest Department, Unidade Local de Sa\u00fade Santa Maria, 1769-001 Lisboa, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-7127-8960","authenticated-orcid":false,"given":"Filipa","family":"Lufinha","sequence":"additional","affiliation":[{"name":"Department of Medicine, Unidade Local de Sa\u00fade Amadora-Sintra, 2720-276 Amadora, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3346-4915","authenticated-orcid":false,"given":"Henrique","family":"Oliveira","sequence":"additional","affiliation":[{"name":"Department of Mathematics and Centre for Mathematical Analysis, Geometry and Dynamical Systems, Instituto Superior T\u00e9cnico, Lisbon University, 1049-001 Lisboa, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"resources","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Ant\u00f3nio","family":"Diniz","sequence":"additional","affiliation":[{"name":"Chest Department, Unidade Local de Sa\u00fade Santa Maria, 1769-001 Lisboa, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Filipe","family":"Froes","sequence":"additional","affiliation":[{"name":"Chest Department, Unidade Local de Sa\u00fade Santa Maria, 1769-001 Lisboa, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"},{"role":"project-administration","vocabulary":"credit"}]},{"given":"Jo\u00e3o","family":"Gon\u00e7alves Pereira","sequence":"additional","affiliation":[{"name":"Emergency and Intensive Care Medicine Department, Hospital Vila Franca de Xira, 2600-009 Vila Franca de Xira, Portugal"},{"name":"Department of Intensive Care Medicine, Faculty of Medicine, Lisbon University, 1649-028 Lisboa, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"project-administration","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1038\/s41572-021-00259-0","article-title":"Pneumonia","volume":"7","author":"Torres","year":"2021","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1111\/joim.12341","article-title":"Clinical risk scores and blood biomarkers as predictors of long-term outcome in patients with community-acquired pneumonia: A 6-year prospective follow-up study","volume":"278","author":"Alan","year":"2015","journal-title":"J. Intern. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1057","DOI":"10.1136\/thoraxjnl-2013-204282","article-title":"Risk factors for community-acquired pneumonia in adults in Europe: A literature review","volume":"68","author":"Torres","year":"2013","journal-title":"Thorax"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e000359","DOI":"10.1136\/bmjresp-2018-000359","article-title":"Lifestyle and comorbid conditions as risk factors for community-acquired pneumonia in outpatient adults (NEUMO-ES-RISK project)","volume":"6","author":"Yuste","year":"2019","journal-title":"BMJ Open Respir. Res."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"104854","DOI":"10.1016\/j.ebiom.2023.104854","article-title":"Differentiating the impacts of ambient temperature on pneumonia mortality of various infectious causes: A nationwide, individual-level, case-crossover study","volume":"98","author":"He","year":"2023","journal-title":"EBioMedicine"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1055\/s-0040-1702193","article-title":"The Role of Streptococcus pneumoniae in Community-Acquired Pneumonia","volume":"41","author":"Feldman","year":"2020","journal-title":"Semin. Respir. Crit. Care Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1264","DOI":"10.1016\/S0140-6736(10)61459-6","article-title":"Viral pneumonia","volume":"377","author":"Ruuskanen","year":"2011","journal-title":"Lancet"},{"key":"ref_8","first-page":"253","article-title":"The benefit of macrolide therapy in patients with pneumococcal pneumonia is only present in patients with bacteremia","volume":"29","author":"Costa","year":"2022","journal-title":"Pulmonology"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e70238","DOI":"10.1111\/irv.70238","article-title":"Incidence of RSV- and Influenza-Associated Hospitalizations with Community-Acquired Pneumonia and Other Acute Respiratory Infection Among Adults in Japan in 2022\u20132024: APSG-J2 Study","volume":"20","author":"Maeda","year":"2026","journal-title":"Influenza Other Respir. Viruses"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2592347","DOI":"10.1080\/25310429.2025.2592347","article-title":"Evolution of hospitalizations of adults for Community-Acquired Pneumonia in Portugal and the impact of pediatric pneumococcal vaccination","volume":"31","author":"Froes","year":"2025","journal-title":"Pulmonology"},{"key":"ref_11","first-page":"e80442","article-title":"Navigating the Future of Elderly Healthcare: A Comprehensive Analysis of Aging Populations and Mortality Trends Using National Inpatient Sample (NIS) Data (2010\u20132024)","volume":"17","author":"Shreya","year":"2025","journal-title":"Cureus"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Gon\u00e7alves-Pereira, J., Froes, F., Pereira, F.G., Diniz, A., Oliveira, H., and Mergulh\u00e3o, P. (2025). Community-acquired pneumonia mortality trends according to age and gender: 2009 to 2019. BMC Pulm. Med., 25.","DOI":"10.1186\/s12890-025-03875-8"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Kang, N., Subramanian, V.S., and Agrawal, A. (2025). Influence of Aging and Immune Alterations on Susceptibility to Pneumococcal Pneumonia in the Elderly. Pathogens, 14.","DOI":"10.3390\/pathogens14010041"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e20260407","DOI":"10.62675\/2965-2774.20260407","article-title":"The challenge of sepsis in older adults in the Emergency Department and intensive care units","volume":"38","author":"Dias","year":"2026","journal-title":"Crit. Care Sci."},{"key":"ref_15","first-page":"287","article-title":"Dysphagia in the elderly: Management and nutritional considerations","volume":"7","author":"Sura","year":"2012","journal-title":"Clin. Interv. Aging"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e263","DOI":"10.1017\/S0950268819001559","article-title":"Pneumonia incidence trends in UK primary care from 2002 to 2017: Population-based cohort study","volume":"147","author":"Sun","year":"2019","journal-title":"Epidemiol. Infect."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Morimoto, K., Suzuki, M., Ishifuji, T., Yaegashi, M., Asoh, N., Hamashige, N., Abe, M., Aoshima, M., and Ariyoshi, K. (2015). Adult Pneumonia Study Group-Japan (APSG-J). The burden and etiology of community-onset pneumonia in the aging Japanese population: A multicenter prospective study. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0122247"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Redondo, E., Rivero-Calle, I., Mascar\u00f3s, E., Oca\u00f1a, D., Jimeno, I., Gil, \u00c1., D\u00edaz-Maroto, J.L., Linares, M., Onieva-Garc\u00eda, M.\u00c1., and Gonz\u00e1lez-Romo, F. (2023). Vaccination against Community-Acquired Pneumonia in Spanish Adults: Practical Recommendations by the NeumoExperts Prevention Group. Antibiotics, 12.","DOI":"10.3390\/antibiotics12010138"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1186\/s41479-026-00201-6","article-title":"A multicentre case-control study about effectiveness of pneumococcal vaccination against pneumonia hospitalization in at-risk adults","volume":"18","author":"Toledo","year":"2026","journal-title":"Pneumonia"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1080\/14760584.2017.1242419","article-title":"Evaluating the costs and benefits of pneumococcal vaccination in adults","volume":"16","author":"Porchia","year":"2017","journal-title":"Expert Rev. Vaccines"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Cafiero-Fonseca, E.T., Stawasz, A., Johnson, S.T., Sato, R., and Bloom, D.E. (2017). The full benefits of adult pneumococcal vaccination: A systematic review. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0186903"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1111\/resp.12978","article-title":"Seasonality of pathogens causing community-acquired pneumonia","volume":"22","author":"Cilloniz","year":"2017","journal-title":"Respirology"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e12","DOI":"10.1016\/S2214-109X(15)00272-7","article-title":"Early identification and treatment of pneumonia: A call to action","volume":"4","author":"Kallander","year":"2016","journal-title":"Lancet Glob. Health"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1874","DOI":"10.4236\/health.2014.614220","article-title":"Projecting Health Outcomes for Portuguese Ageing Population: Challenges and Opportunities","volume":"6","author":"Rodrigues","year":"2014","journal-title":"Health"},{"key":"ref_25","first-page":"625","article-title":"Community-Acquired Pneumonia in Adults: Rapid Evidence Review","volume":"105","author":"Womack","year":"2022","journal-title":"Am. Fam. Physician"},{"key":"ref_26","first-page":"260","article-title":"Epidemiology of community-acquired pneumonia in the elderly","volume":"5","author":"Marrie","year":"1990","journal-title":"Semin. Respir. Infect."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Li, S., Li, L., Wang, S., and Wu, H. (2025). Clinical characteristics and risk factors of hospital mortality in elderly patients with community-acquired pneumonia. Front. Med., 12.","DOI":"10.3389\/fmed.2025.1512288"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1141","DOI":"10.1183\/09031936.00216711","article-title":"Hospital admissions of adults with community-acquired pneumonia in Portugal between 2000 and 2009","volume":"41","author":"Froes","year":"2013","journal-title":"Eur. Respir. J."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"190126","DOI":"10.1183\/16000617.0126-2019","article-title":"Community-acquired pneumonia in critically ill very old patients: A growing problem","volume":"29","author":"Torres","year":"2020","journal-title":"Eur. Respir. Rev."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"552","DOI":"10.1177\/08258597211020964","article-title":"The PALliative MUlticenter Study in Intensive Care (PalMuSIC). Results from a Multicenter Study Addressing Frailty and Palliative Care Interventions in Intensive Care Units in Portugal","volume":"37","author":"Correia","year":"2021","journal-title":"J. Palliat. Care"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"12371","DOI":"10.1038\/s41598-026-48112-2","article-title":"Antimicrobial use at the end of life: A retrospective cohort study","volume":"16","author":"Sandqvist","year":"2026","journal-title":"Sci. Rep."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"L\u00fcthi-Corridori, G., Boesing, M., Roth, A., Giezendanner, S., Leuppi-Taegtmeyer, A.B., Schuetz, P., and Leuppi, J.D. (2023). Predictors of Length of Stay, Rehospitalization and Mortality in Community-Acquired Pneumonia Patients: A Retrospective Cohort Study. J. Clin. Med., 12.","DOI":"10.3390\/jcm12175601"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"845","DOI":"10.1016\/j.amjmed.2008.05.010","article-title":"Declining Length of Hospital Stay for Pneumonia and Postdischarge Outcomes","volume":"121","author":"Capelastegui","year":"2008","journal-title":"Am. J. Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"6116","DOI":"10.1038\/s41598-026-36609-9","article-title":"Prognostic factors for severe community-acquired pneumonia in high altitude areas","volume":"16","author":"Zhang","year":"2026","journal-title":"Sci. Rep."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1007\/s00134-026-08361-1","article-title":"Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2026","volume":"52","author":"Prescott","year":"2026","journal-title":"Intensive Care Med."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"e20250344","DOI":"10.62675\/2965-2774.20250344","article-title":"Intensive Care Medicine in Portugal","volume":"37","author":"Moreno","year":"2025","journal-title":"Crit. Care Sci."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1647","DOI":"10.1007\/s00134-012-2627-8","article-title":"The variability of critical care bed numbers in Europe","volume":"38","author":"Rhodes","year":"2012","journal-title":"Intensive Care Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1217","DOI":"10.1016\/j.jcrc.2015.07.007","article-title":"Epidemiological trends in invasive mechanical ventilation in the United States: A population-based study","volume":"30","author":"Mehta","year":"2015","journal-title":"J. Crit. Care"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1016\/j.aenj.2013.12.002","article-title":"What is the seasonal distribution of community acquired pneumonia over time? A systematic review","volume":"17","author":"Murdoch","year":"2014","journal-title":"Australas. Emerg. Nurs. J."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"100757","DOI":"10.1016\/j.lanepe.2023.100757","article-title":"Ambient temperature and seasonal variation in inpatient mortality from respiratory diseases: A retrospective observational study","volume":"35","author":"Achebak","year":"2023","journal-title":"Lancet Reg. Health Eur."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1016\/j.arbr.2013.02.004","article-title":"Do Seasonal Changes and Climate Influence the Etiology of Community Acquired Pneumonia?","volume":"49","year":"2013","journal-title":"Arch. Bronconeumol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"220222","DOI":"10.1183\/20734735.0222-2022","article-title":"Climate change and respiratory disease: Clinical guidance for healthcare professionals","volume":"19","author":"Andersen","year":"2023","journal-title":"Breathe"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"2457","DOI":"10.1038\/s41467-020-16273-x","article-title":"Reversal of the seasonality of temperature-attributable mortality from respiratory diseases in Spain","volume":"11","author":"Achebak","year":"2020","journal-title":"Nat. Commun."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Brown, J.D., Harnett, J., Chambers, R., and Sato, R. (2018). The relative burden of community-acquired pneumonia hospitalizations in older adults: A retrospective observational study in the United States. BMC Geriatr., 18.","DOI":"10.1186\/s12877-018-0787-2"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"694","DOI":"10.1055\/s-0044-1791827","article-title":"Medications to Modify Aspiration Risk: Those That Add to Risk and Those That May Reduce Risk","volume":"45","author":"Froes","year":"2024","journal-title":"Semin. Respir. Crit. Care Med."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Yoshimatsu, Y., and Smithard, D.G. (2022). A Paradigm Shift in the Diagnosis of Aspiration Pneumonia in Older Adults. J. Clin. Med., 11.","DOI":"10.3390\/jcm11175214"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"923","DOI":"10.1183\/09031936.00019012","article-title":"Oropharyngeal dysphagia is a risk factor for community-acquired pneumonia in the elderly","volume":"41","author":"Almirall","year":"2013","journal-title":"Eur. Respir. J."},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Lim, H.J., Lai, D.K.H., So, B.P.H., Yip, C.C.K., Cheung, D.S.K., Cheung, J.C.W., and Wong, D.W.C. (2023). A Comprehensive Assessment Protocol for Swallowing (CAPS): Paving the Way towards Computer-Aided Dysphagia Screening. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20042998"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1016\/j.pulmoe.2022.03.005","article-title":"The Vacin\u00f3metro\u00ae initiative: An eleven-year monitorization of influenza vaccination coverage rates among risk groups in Portugal","volume":"28","author":"Froes","year":"2022","journal-title":"Pulmonology"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1016\/j.trivac.2016.04.004","article-title":"A post hoc assessment of duration of protection in CAPiTA (Community Acquired Pneumonia immunization Trial in Adults)","volume":"5","author":"Patterson","year":"2016","journal-title":"Trials Vaccinol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1016\/j.eclinm.2018.12.007","article-title":"Effectiveness of 23-Valent Polysaccharide Pneumococcal Vaccine and Changes in Invasive Pneumococcal Disease Incidence from 2000 to 2017 in Those Aged 65 and Over in England and Wales","volume":"6","author":"Djennad","year":"2018","journal-title":"EClinicalMedicine"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e221111","DOI":"10.1001\/jamanetworkopen.2022.1111","article-title":"Incidence and Estimated Vaccine Effectiveness Against Hospitalizations for All-Cause Pneumonia among Older US Adults Who Were Vaccinated and Not Vaccinated with 13-Valent Pneumococcal Conjugate Vaccine","volume":"5","author":"Hsiao","year":"2022","journal-title":"JAMA Netw. Open"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1093\/aje\/kwy219","article-title":"Association Between the Decline in Pneumococcal Disease in Unimmunized Adults and Vaccine-Derived Protection Against Colonization in Toddlers and Preschool-Aged Children","volume":"188","author":"Weinberger","year":"2019","journal-title":"Am. J. Epidemiol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1093\/infdis\/jiv431","article-title":"Association Between Local Pediatric Vaccination Rates and Patterns of Pneumococcal Disease in Adults","volume":"213","author":"Pingali","year":"2016","journal-title":"J. Infect. Dis."}],"container-title":["Epidemiologia"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2673-3986\/7\/5\/125\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T09:31:15Z","timestamp":1788859875000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2673-3986\/7\/5\/125"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,8]]},"references-count":54,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,10]]}},"alternative-id":["epidemiologia7050125"],"URL":"https:\/\/doi.org\/10.3390\/epidemiologia7050125","relation":{},"ISSN":["2673-3986"],"issn-type":[{"value":"2673-3986","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,8]]}}}