IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
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IntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
With the desire to make book publishing more relevant for the digital age and offer innovative Open Access publishing options, we are thrilled to announce the launch of our new publishing format: IntechOpen Book Series.
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Designed to cover fast-moving research fields in rapidly expanding areas, our Book Series feature a Topic structure allowing us to present the most relevant sub-disciplines. Book Series are headed by Series Editors, and a team of Topic Editors supported by international Editorial Board members. Topics are always open for submissions, with an Annual Volume published each calendar year.
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After a robust peer-review process, accepted works are published quickly, thanks to Online First, ensuring research is made available to the scientific community without delay.
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Our innovative Book Series format brings you:
\n\n
\n\t
Topic Focused Publications - Each topic showcases high impact subject areas
\n\t
Renowned Editorial Expertise - Series Editors, Topic Editors, and a team of international Board Members that permanently support each Book Series
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Fast Publishing - quick turnaround which is unique for book publishing
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The benefit of ISSN and ISBN for increased citation and indexing possibilities
\n
\n\n\n\n
IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\n\n
IntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
We invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
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Note: Edited in October 2021
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It represents a very important, innovative, and current attempt to describe new forms of social exclusion in society and takes into account the contribution of different disciplines with different points of view. The authors offer a very interesting and novel contribution to the field of new forms of social exclusion, reporting their theoretical perspectives, the original results of their research, and their discussions. "Exclusion is always dangerous. Inclusion is the only safety if we are to have a peaceful world." Pearl S. 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She aims to develop new techniques and approaches in cognitive science and social neuroscience. She is an expert in experimental neuroscience, neuroeconomics, psychophysiology, and cognitive and social neuroscience. She performs neuroimaging studies in social contexts in order to investigate neural correlates involved during social interactions, such as, social exclusion, social support, empathy, communicative intention, social decision-making, in-group and out-group settings, etc. She currently works at Università della Svizzera italiana, Lugano, Switzerland.\n\nFor more information: http://usi.to/xuj",institutionString:"Faculty of Biomedical Sciences",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"8",totalChapterViews:"0",totalEditedBooks:"4",institution:{name:"Universita della Svizzera Italiana",institutionURL:null,country:{name:"Switzerland"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"233998",title:"Ph.D.",name:"Sara",middleName:null,surname:"Palermo",slug:"sara-palermo",fullName:"Sara Palermo",profilePictureURL:"https://mts.intechopen.com/storage/users/233998/images/system/233998.png",biography:"Sara Palermo has an MSc in clinical psychology and a PhD in experimental neuroscience. 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In this chapter, it is defined as a possible ability of an individual or a group to face, manage, and anticipate a possible problem. This concept of vulnerability is associated with that of risk factor for social isolation, and therefore to situations that can also lead to illness and lack of mental and physical health. It can have its roots in poverty, in social exclusion, in ethnicity, in disability or simply in disease or specific developmental phases in life. All these aspects reflect very important vulnerability factors among biological, psychological, social, and behavioral variables. To date, no one has highlighted together two critical moments in life in which this brain area undergoes important variations: adolescence, in which its development occurs, and old age, in which this area goes into cognitive decline with the relative loss of many higher cognitive functions. This knowledge can help to better understand the forms of exclusion due to vulnerability in order to develop new forms of social inclusion.",signatures:"Rosalba Morese, Sara Palermo, Matteo Defedele, Juri Nervo and Alberto Borraccino",downloadPdfUrl:"/chapter/pdf-download/66422",previewPdfUrl:"/chapter/pdf-preview/66422",authors:[{id:"214435",title:"Dr.",name:"Rosalba",surname:"Morese",slug:"rosalba-morese",fullName:"Rosalba Morese"},{id:"233998",title:"Ph.D.",name:"Sara",surname:"Palermo",slug:"sara-palermo",fullName:"Sara Palermo"},{id:"218983",title:"BSc.",name:"Juri",surname:"Nervo",slug:"juri-nervo",fullName:"Juri Nervo"},{id:"218984",title:"MSc.",name:"Matteo",surname:"Defedele",slug:"matteo-defedele",fullName:"Matteo Defedele"},{id:"266453",title:"Prof.",name:"Alberto",surname:"Borraccino",slug:"alberto-borraccino",fullName:"Alberto Borraccino"}],corrections:null},{id:"63833",title:"Living in Italy in an Anti-Immigrant Scenario: New Challenges for Muslim Second Generations",doi:"10.5772/intechopen.81280",slug:"living-in-italy-in-an-anti-immigrant-scenario-new-challenges-for-muslim-second-generations",totalDownloads:853,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Analysing whether and how the transition from the first to the second generation transforms adherence to Islam in Italy, a Catholic country which is undergoing a Lively immigration and Muslim-welcoming debate, is extremely interesting. The growing presence of Muslims in Italy stresses relations with ‘diversity’, especially in those areas where the incidence of migrants coming from Maghreb is higher and where there is an Arabic presence visible through ethnic shops, women wearing the chador and men wearing long robes. In these areas, the issues of control and safety have been on the agenda for many years. On the other hand, according to Muslim organizations there is a common interest in presenting a ‘moderate Islam’. There is a specific will and interest of the youngest Muslim generations to demonstrate their propensity to promote integration, using both old (debates, meetings, etc.) and new (websites, blog, etc.) policy tools.",signatures:"Roberta Ricucci",downloadPdfUrl:"/chapter/pdf-download/63833",previewPdfUrl:"/chapter/pdf-preview/63833",authors:[{id:"258433",title:"Associate Prof.",name:"Roberta",surname:"Ricucci",slug:"roberta-ricucci",fullName:"Roberta Ricucci"}],corrections:null},{id:"63724",title:"Social Exclusion and Territorial Dispossession: A Reflection on Mining Activity in Peru and Mexico",doi:"10.5772/intechopen.80689",slug:"social-exclusion-and-territorial-dispossession-a-reflection-on-mining-activity-in-peru-and-mexico",totalDownloads:749,totalCrossrefCites:0,totalDimensionsCites:2,hasAltmetrics:0,abstract:"From the social struggles that are found all over the globe, it is important to try to analyze the territorial dispossession suffered by the peasant communities, by the transnational mining companies. For this, we rely on categories such as accumulation through elimination in order to know if social exclusion is an event in the development of capitalism or responds to an abrupt struggle between labor and capital. In this sense, we are interested in focusing our study on two cases that are found in Peru and Mexico. In such regions, social mobilization has not only developed as a generalized form of rejection of mining but also accounts for the contradictions of the mining industry.",signatures:"John Kenny Acuña Villavicencio",downloadPdfUrl:"/chapter/pdf-download/63724",previewPdfUrl:"/chapter/pdf-preview/63724",authors:[{id:"259795",title:"Dr.",name:"J. Kenny",surname:"Acuña Villavicencio",slug:"j.-kenny-acuna-villavicencio",fullName:"J. 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\r\n\tRubber Materials are used across a huge range of domestic and industrial applications. There are ten common types of rubber Natural Rubber, Styrene-butadiene rubber, Butyl, Nitrile, Neoprene®, Ethylene Propylene Diene Monomer, Silicone, Polyurethane, and Hydrogenated Nitrile. Their properties and applications are important for domestic and industrial applications.
\r\n
\r\n\tThe scope of this book covers four areas of rubber material as its properties and characterizations of them. Their mechanical, optical, and acoustic properties and kinetics are covered in the book. Firstly, their elasticity, toughness, modulus, compression, and extension parameters are significant concerning their mechanical properties. Secondly, their optical properties of them can be characterized by spectroscopic techniques such as fluorescence and UV measurements. Thirdly, their swelling, drying, diffusion, and release parameters are obtained as their kinetics of them. Lastly, the parameters such as transmission loss, sound absorption coefficient, and acoustic impedance are given as acoustical performance of them in this book. \r\n\t
",isbn:"978-1-80355-607-9",printIsbn:"978-1-80355-606-2",pdfIsbn:"978-1-80355-608-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"6cf0b844f6881c758c61cca10dc8b134",bookSignature:"Associate Prof. Gülşen Akın Evingür and Dr. Önder Pekcan",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11830.jpg",keywords:"Elasticity, Toughness, Modulus, Compression, Extension, Optical Properties, Swelling, Drying, Diffusion, Release, Transmission Loss, Sound Absorption Coefficient",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 5th 2022",dateEndSecondStepPublish:"June 15th 2022",dateEndThirdStepPublish:"August 14th 2022",dateEndFourthStepPublish:"November 2nd 2022",dateEndFifthStepPublish:"January 1st 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Evingür is a researcher in polymer composites and a lecturer at a maritime university. She has edited 2 books and has had 5 chapters published in international books, and 3 international and 5 national projects, respectively.",coeditorOneBiosketch:"Prof. Pekcan received their Ph.D. from the University of Wyoming, United States of America, in 1974. He has more than 362 SCI articles, 26 chapters, and 10 projects and is a member Science Academy in Turkey.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"180256",title:"Associate Prof.",name:"Gülşen",middleName:null,surname:"Akın Evingür",slug:"gulsen-akin-evingur",fullName:"Gülşen Akın Evingür",profilePictureURL:"https://mts.intechopen.com/storage/users/180256/images/system/180256.jpeg",biography:"Gülşen Akın Evingür graduated from Physics Department at the Yıldız Technical University (YTU, İstanbul, Turkey) in 1996. She completed her Master of Science degree in 2002 at the same department. The titled of her thesis was 'Electrical Properties of Polystyrene”. She received her PhD from Physics Engineering at İstanbul Technical University in 2011. The title of the thesis was 'Phase Transitions in Composite Gels”. She worked as an Assistant Professor between 2011 and 2018, and she is currently working as an Assosciate Professor at Pîrî Reis University, Istanbul, Turkey. She has been engaged in various academic studies in the fields of composites and their mechanical, optical, electrical, and acoustic properties. She has authored more than 60 SCI articles, 92 proceedings in national and international journals, respectively. 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He became Associate Professor at Hacettepe University in 1979. \nHe visited ICTP Trieste, Italy as Visiting Scientist between June and August 1980. Between 1980 and 1981 he was a Visiting Scientist at the Technical University of Gdansk, Poland. \nHe worked as Visiting Professor at the Department of Chemistry, University of Toronto, Canada between 1981 and 1988. \nHe was appointed as full Professor at the Department of Physics, Istanbul Technical University, Turkey and worked there between 1988 and 2005. \nHe became an Elected Member of the Turkish Academy of Sciences (TÜBA) in January 1995. \nHe became the Dean of School of Arts and Sciences at the Istanbul Technical University in 1997. \nHe received the Science Award from the Scientific and Technological Research Council of Turkey (TÜBİTAK) in 1998. 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1. Introduction
Coronaviruses are enveloped, positive-sense RNA viruses belonging to the subfamily Coronavirinae in the family Coronaviridae and cause serious respiratory ailments in humans [1]. In the last 20 years, three different types of coronavirus, including Middle-East respiratory syndrome coronavirus (MERS-CoV), severe acute respiratory syndrome coronavirus (SARS-CoV) and SARS-CoV-2, respectively, have caused severe respiratory tract infections and fatal outbreaks. SARS-CoV-2 emerged in Wuhan, China in December 2019 and has rapidly become an international health emergency [2]. In March 2020, the World Health Organization (WHO) has declared novel coronavirus disease 2019 (COVID-19) pandemic.
SARS-CoV-2 uses the angiotensin-converting enzyme 2 (ACE2) receptor for viral entry, as in SARS-CoV [3]. One of the major structural proteins, the glycoprotein Spike (S) of the SARS-CoV-2 binds to surface receptor (ACE2) of the host cell and mediates viral entry. S protein is composed of two domains; S1 domain contains receptor-binding region, while S2 domain manages viral fusion with the membrane of the host cell. Host transmembrane protease serine type 2 (TMPRSS2) cleaves the S protein into S1 and S2 domains upon virus binding to ACE2 [3, 4, 5]. SARS-CoV-2 receptor binding and fusion of viral membrane and cell membrane initiate viral infection.
ACE2 protein is expressed in a variety of human organs and tissues, including ocular tissues ranging from conjunctiva to retina [6, 7]. Understanding the transmission paths of SARS-CoV-2 is crucial to prevent the viral spread. Current studies show that SARS-CoV-2 could be transmitted via direct contact or aerosol droplets. Ocular surfaces are possible viral entry and infection sites, or gateway for spread of the virus to the respiratory system [8, 9]. Although ocular symptoms are rare in COVID-19 patients, manifestations affecting the ocular surfaces such as conjunctivitis, epiphora, chemosis [10, 11], retinal hemorrhages, central retinal vein occlusion (CRVO), ischemia [12, 13, 14, 15] as well as blurred vision and vision loss [16, 17] have been reported.
This chapter focuses on the presence and the effects of cellular receptors of SARS-CoV-2 on ocular tissues, evaluates the potential ocular transmission through the eyes, and discusses the short and long-term effects and manifestations of the virus on ocular surfaces at the molecular level.
2. ACE2 and TMPRSS2 expression profiles in ocular tissues
In 2020, various cases of positive conjunctival swabs and conjunctivitis were reported as COVID-19 symptoms. Therefore, several researchers have investigated the ocular surfaces as a potential infection route for SARS-CoV-2 [18, 19]. To this end, intensive research focused on the presence of ACE2 and TMPRSS2 receptors in various ocular tissues since both receptors play important roles in the entry of SARS-CoV-2 to the host cells [20, 21].
ACE2 is an important component of Renin-Angiotensin System (RAS). The circulatory RAS is composed of certain enzymes and active-inactive peptides and plays crucial roles in human body including the regulation of blood pressure, fluid volumes and electrolyte homeostasis [22, 23, 24, 25, 26, 27]. These regulations are controlled through the digestion of Angiotensinogen by Renin to generate Angiotensin I and transformation of Angiotensin I to the active form Angiotensin II by angiotensin-converting enzyme (ACE). Recently, Renin and ACE independent generation of Angiotensin II has also been reported [27]. In addition to the circulatory system, RAS is also found locally in some tissues and two separate research groups, Fischer-Ferraro et al. and Ganten et al. discovered the first clues on local RAS and its tissue-specific roles in 1971 [28, 29]. To date, local RAS has been reported in various organs such as brain, heart, intestine, kidney, and the eye [30, 31]. The presence of RAS in the eye suggested its involvement in various ocular diseases such as age-related macular degeneration (AMD), diabetic retinopathy, and glaucoma [22].
ACE2 is a carboxypeptidase found in circulatory system and in some tissues and regulates RAS negatively by cleaving angiotensin II [21]. This carboxypeptidase is structurally similar to angiotensin converting enzyme (ACE) with a 42% sequence similarity [32]. ACE2 was first discovered and cloned in 2000 as a counter-regulator of ACE, which generates Angiotensin (1–7) by cleaving a single residue from Angiotensin II or Angiotensin (1–9) by removing single residue from Angiotensin I [32, 33, 34, 35]. In the eye, ACE2 expression has been demonstrated in a wide variety of ocular tissues, including aqueous humor, retina, corneal epithelium, conjunctival epithelium, and limbal epithelium [6, 7, 22]. ACE2 is found to decrease intraocular pressure (IOP) upon activation with chemical inducers [36].
In addition to ACE2, recent studies showed that TMPRSS2 receptor was also contributing to the cell entry of SARS-CoV-2 by cleaving the spike protein after its’ binding to ACE2 receptor [6, 37, 38]. TMPRSS2 is one of the serine proteases, involved in various physiological and pathological processes, including protein catabolism, blood coagulation and tissue rearrangement [39, 40]. As a homologous to enterokinase, the function of TMPRSS2 is suggested to be similar to enterokinase that cleaves acidic pro-peptide from trypsinogen to generate active enzyme. However, exact physiological functions of TMPRSS2 are still not clear [40, 41]. Many ocular surfaces express TMPRSS2 receptor such as conjunctiva and corneal stroma [42].
Due to the important roles of ACE2 and TMPRSS2 in SARS-CoV-2 infection, their individual and co-expression in ocular tissues is investigated [43]. In an early study, local ACE2 expression in rodent retina was evaluated by using immunoblotting, immunohistochemistry analyses and mRNA levels. Expression of ACE2 was broadly localized in the inner nuclear layer and photoreceptors of rodent retinas [44]. Similarly, TMPRSS2 expression was also shown in the retina [45]. One of the most comprehensive studies on this subject was the investigation of coronavirus-2 (CoV-2) tropism in ocular tissues [6]. Here, co-expression of ACE2 receptor and TMPRSS2 protease was shown in human adult conjunctival, limbal and corneal epithelium but not in embryonic and fetal ocular tissues [6]. On the other hand, comparative RNA expression levels of ACE2 and TMPRSS2 in various tissues suggested ACE2 being the limiting factor for infection because TMPRSS2 expression showed a broader tissue distribution [46]. Similarly, expression of ACE2 and TMPRSS2 in post-mortem eyes of non-diabetic and diabetic retinopathy specimens revealed significantly strong expression of ACE2 in corneal and conjunctival epithelium while broad expression of TMPRSS2 in all ocular surfaces [42]. A comparable expression pattern with post-mortem eyes was found in five surgical conjunctival specimens as well, only with higher ACE2 staining intensity in the surgical specimen [42].
Co-expression profile of ACE2 and TMPRSS2 genes shows some contradicting expression profiles between human primary conjunctival and pterygium cells and different cell lines including ARPE-19, HUVEC, HaCaT, HepG2, and A549 [37]. For instance, persistent expression of ACE2 and TMPRSS were observed in conjunctival and pterygium cells of some patients, which was concluded not to be enough for SARS-CoV-2 cell entry [37]. In contrast, a significantly higher gene expression of TMPRSS2 and a lower but notable ACE2 gene expression in studied ocular (ARPE-19, HUVEC) and lung cell (A549) lines were observed [37]. Investigation of healthy and diseased conjunctival samples for mRNA expression levels of ACE2 and TMPRRS2, and ACE2 protein expression by immunostaining revealed ACE2 expression in conjunctival samples [47]. However, protein expression of ACE2 and other SARS-CoV-2 mediators of cell entry found not significant enough for the infection [47]. On the other hand, the expression of ACE2 and TMPRSS2 in ocular epithelium such as corneal epithelial cells, conjunctival epithelial cells and corneal endothelial cells is also reported. Herein, co-expression of ACE2 and TMPRSS2 in corneal epithelium and endothelium suggested the susceptibility of cornea for a potential SARS-CoV-2 infection site (Figure 1) [48].
Figure 1.
Representative schematic of the relative expression profile of ACE2 and TMPRSS2 in ocular surfaces. (This schematic was created using Servier Medical Art templates, which are licensed under a Creative Commons Attribution 3.0 Unported License; https://smart.servier.com).
3. Potential systemic invasiveness of SARS-CoV-2 following ocular transmission
The three human coronaviruses, SARS-CoV, MERS-CoV, and SARS-CoV-2 are highly infectious compared to HCoV-229-E, HCoV-NL63, HCoV-OV43, and HCoV-HKU1, which infect upper respiratory tract with mild symptoms. On the other hand, SARS-CoV, MERS-CoV, and SARS-CoV-2 cause severe lower respiratory tract infection, which then leads to pneumonia [49]. The transmission mechanism of SARS-CoV and SARS-CoV-2 are similar in many aspects. These viruses could be transmitted with direct contact, droplet, or aerosolized particle contact with the eye surface, nose, and mouth [9]. SARS-CoV and SARS-CoV-2 are genetically similar as well. However, the number of patients infected with SARS-CoV-2 is hundreds of times higher, indicating a significantly higher transmission rate compared to SARS-CoV and MERS-CoV [50]. It’s also recently shown that the rate of SARS-CoV-2 replication in conjunctiva is higher than SARS-CoV and MERS-CoV [51].
Potency of viral infections are mainly affected by the virus invasiveness, receptor repertoire of the host cell membrane, and the immune system response. The first step for the viral invasion is the binding of the virus to the host cell by its receptors [52]. Glycoproteins and spike proteins are well-known proteins for all coronaviruses that bind to the receptor of the host cell and trigger the viral entry. The spike proteins are encoded in β-coronaviruses and today, it has been known that SARS-CoV-2 spike protein has the receptor-binding domain, mediating the interaction with the host cell membrane receptor, ACE2 [53].
The eye is an organ representing a large surface area and could be easily exposed to external pathogenic factors. The large surface area of the eye is a potential landing zone for viral particles [54]. Importantly, the expression of TMPRSS2, CD147, ACE2, and CTSL proteins in ocular tissues indicate their potential as SARS-CoV-2 entry route [55, 56, 57]. Confirmed expression of ACE2 and TMPRSS2 in conjunctival and corneal tissues [46] suggest conjunctiva and cornea as ocular regions for SARS-CoV-2 entry [8, 49].
Ocular exposure may lead to systemic transmission of the SARS-CoV-2 virus via two pathways. In first pathway, cornea, conjunctiva, lacrimal gland, meibomian glands could be directly exposed to the infection. Particularly, the conjunctival tissue could be easily infected via droplets or a close contact with infected individuals and contaminated hands. Due to its potency as an entry site of viruses, conjunctiva is accepted as an important pathway for infection of the respiratory viruses [52]. In second pathway, virus in tear can migrate through the nasolacrimal duct and infect the nasal or gastrointestinal epithelium [9].
SARS-CoV-2 may indirectly enhance the possibility of ocular complications as well. For instance, the cytokine storm, vascular endothelial dysfunction, and hypercoagulability may lead to not only retinal microangiopathic changes but also congestion of the central retinal vessels, or micro-vascularization of the optic nerve head [14, 58, 59]. It has been also reported that SARS-CoV-2 led to paracentral acute middle maculopathy and acute macular neuro-retinopathy [60, 61]. In May 2020, retinal changes in 12 adult COVID-19 patients were analyzed by using optical coherence tomography (OCT). Hyper-reflective lesions were observed at the ganglion cell level and interestingly, inner plexiform layers were found more prominently at the papillomacular bundle in both eyes [14]. A 40-year-old man diagnosed with SARS-CoV-2 infection reported that he had right calf pain and blurred vision in both eyes. His ophthalmic exam revealed retinal vein occlusion (RVO) on both eyes, indicating COVID-19 as a potential cause for RVO [12].
On the other hand, the viral infection can occur at the upper respiratory tract and viruses can migrate to the nasolacrimal duct and to the conjunctiva, resulting in viral conjunctivitis [62]. Furthermore, SARS-CoV-2 infection via the conjunctival tissues may also occur in non-human primates that the SARS-CoV-2 inoculation has been shown to cause mild COVID-19 in rhesus macaques [63].
3.1 Natural ocular defense mechanisms
The eye has natural anatomical and physiological protection mechanisms that prevent the entry of large amounts of virus-loaded particles to the ocular surface [64]. The eye has three defense mechanisms against different types of microorganisms and toxic substances. These are; mechanical, immunological, and anatomical defense mechanisms which are critical to recognize and eliminate the pathogens from the ocular surface for eye protection [65].
Mechanical defense system is composed of eyelids, eyelashes, corneal epithelium containing tight intercellular junctions, and conjunctival mucosa. Corneal epithelial cells also protects the ocular surface by secreting cytokines and causing immune defense activation against the viral invasion [65]. Eyelid protects the eye surface against any mechanical injury. When the eyelids and lashes are closed, the eye is also protected from any exposure of pathogens and other foreign molecules such as dust, dirt, and any other debris [66].
Anatomical defense system is based on the barriers of anterior and posterior segments of the eye. The drugs administered to the eye is extensively drained by the precorneal barriers present in the anterior segment (around 90%) and tears migrate through the nasolacrimal duct [67]. Aqueous humor is secreted by the ciliary body and the flow direction of the aqueous humor is towards the cornea, which is an opposite direction of topically administrated drug. The aqueous humor can be a limiting factor for the drugs to show therapeutic effects. Sclera presents at the posterior segment of the eye and protects the eye from the exogenous substances. Surface charge, physicochemical properties, and molecular radius are the parameters affecting the drug permeability across sclera. The drug with greater molecular radius and lipophilicity can lead to inhibition of permeation across sclera [67]. On the other hand, the pathogens are also cleaned from the ocular surface with the lacrimal drainage system. However, this physical self-cleaning system may cause SARS-CoV-2 infection via the migration of infected tears throughout the nasolacrimal drainage system and this passage can function as an alternative entry route of the virus from ocular surface to the respiratory tract [68].
Immune defense at the ocular surface is important for preservation of the eye. Particularly, cornea have a variety of defense mechanisms; classified as native, nonspecific, and acquired immunological defenses.
Innate immunity is the first line of defense mechanism in corneal infection; presents at birth and provides a nonspecific defense system [65]. This system can function in case of viral load and pathogenesis. Innate immune response is given at first encounter with the pathogen and can vary between different pathogens. For instance, among SARS-CoV viruses, the replication of the SARS-CoV-2 has been more extensive in the bronchus than SARS-CoV and the higher plasma concentrations of proinflammatory cytokines have been observed in the SARS-CoV-2-infected patients [9].
Tears, corneal nerves, epithelium, keratocytes, polymorphonuclear cells and some cytokines are other cellular and molecular elements for protection of cornea against microorganisms. The first function of tears is to keep the cornea not to be dried. Tears clean the foreign particles from the ocular surface and transports antimicrobial proteins lactoferrin, lysozyme, lipocalin, and beta-lysine to prevent the infections. In addition to these proteins, immunoglobulins protect the cornea from infections [65]. Lactoferrin is able to inhibit the binding of SARS-CoV-2 to ACE2, and IgA shows an effective immune response against different types of microorganisms [65, 69]. For instance, secreted IgA protects the corneal epithelium by binding to bacteria and prevents it from attaching to epithelium. Besides, IgG has the ability to bind bacteria and neutralize some viruses.
Corneal epithelial cells activate immune response by secreting cytokines to preserve the eye against microbial invasion. They store IL-1α to release it passively, when the trauma or any foreign agent stimulates the membrane. Keratocytes synthesize IL-6 and defensins as a defense mechanism. IL-6 and IL-1 show a synergetic effect against microbial activity. Defesin has antimicrobial activity in ocular infections and induce epithelial healing. It is also found in neutrophils located in conjunctiva. Corneal nerves send sensory information and therefore control the reflexive movements for protection of the eye. Furthermore, several other eye complements, composed of a variety of effectors and regulatory proteins activating each other to produce biologically active molecules, such as opsonins, enzymes and chemotaxins [65].
There are early and late defense stages of relevant innate and acquired immune responses. The immediate immune response takes minutes to several hours against microbial infection. When the innate immunity is unable to fight against the microorganisms or their antigens, acquired immunity can control microbial replication. Langerhans cells, antigen-presenting cells of the cornea, recognize the foreign antigen and can respond within 24–48 hours [65]. They recognize, process and present the antigens with MHC class II molecules, which are present on their surface. When they recognize an antigenic foreign molecule, they process the antigen and transport it to the surface by MHC molecules both class I and class II. The presentation of peptides by MHC molecules activates T cells and T-cell receptors, which then lead to the binding of MHC molecules to each other. If the MHC II molecule presents the antigen, then CD4 helper T cells kill the pathogen by secretion of cytokines that activates the other effector cells such as macrophages [65].
3.2 Nasolacrimal duct can play a role in SARS-CoV-2 systemic transmission
The human tear ducts consist of the upper and lower lacrimal canaliculus, lacrimal sac, and nasolacrimal duct (Figure 2) [70]. The nasolacrimal system functions as a bridge between the ocular surface mucosa and upper respiratory tract for migration of the viruses with the help of tears to the inferior meatus of the nose. It allows the virus to move from the ocular surface to the respiratory tract throughout the nasolacrimal duct [52, 71]. The fluid may be taken up by the conjunctiva, sclera, or cornea but the highest percent of the liquid is drained into the nasopharyngeal space. Additionally, the epithelial lining of the lacrimal duct can absorb the tear fluid, which allows immunizing agents to be drained to nasal tissue [72].
Figure 2.
Representative schematic of ocular surface and tear ducts (This schematic was created using Servier Medical Art templates, which are licensed under a Creative Commons Attribution 3.0 Unported License; https://smart.servier.com).
In addition to the above-mentioned functions of nasolacrimal duct, it has a role in nonspecific immune defense. Nasolacrimal duct protects against dacryocystitis; thus, the epithelial cells produce a variety of antimicrobial substances, such as lysozyme and lactoferrin. In case of an infection or an inflammatory dacryocystitis, antimicrobial peptides human inducible beta defensins 2 and 3 are produced. Moreover, the secretory products of the mucus component mucins (MUC1, MUC2, MUC4, MUC5AC, MUC5B, and MUC7) are produced by goblet and epithelial cells. Mucins preserve mucosal surfaces against pathogenic substances. It has been observed that MUC5B protects the patient against the SARS-CoV-2. There is a lower allelic frequency of the MUC5B genetic variant in the COVID-19 patient’s body compared the healthy people, which is related to a higher level of MUC5B expression [73]. On the other hand, the expression of MUC1 and the soluble mucin MUC5AC were observed in cells that also express ACE2, indicating that the mucins may function in entry and transmission of the SARS-CoV-2 [46, 74]. However, it was revealed that the increased levels of secreted MUC1 and MUC5AC in the sputum cleaned from the trachea of COVID-19 patients [75]. The epithelium present in the nasolacrimal duct produces TFF peptides TFF1 and TFF3. The efferent tear ducts also contain lymphocytes and other defense cells that function in adaptive immune mechanisms [70].
Nasolacrimal duct has common entry receptors for some respiratory viruses. For instance, the glycoproteins of host epithelial cell, carrying terminal sialic acid (SA), are distributed through the ocular tissue and the respiratory tract through the lacrimal passage. Thus, the patient becomes infected with pneumonia [71]. α2–6-linked SA is significantly abundant in trachea and nasal mucosa, while α2–3- linked SA are more prominent in ocular tissues and the lower respiratory tract tissues [72]. There are several reports hypothesized that the exposure of the ocular surface to SARS-CoV-2 may lead to infection, because of the drainage of the virus particles via the nasolacrimal duct [76]. Siedlecki et al. has shown that SARS-CoV-2 can infect the ocular surface by migrating into the respiratory tract with the help of tears through the nasolacrimal duct [77]. Supporting to this, the highest expression level of SARS-CoV-2 entry factors was shown in nasal epithelial cells (clusters of goblet cells and ciliated cells), among all cells present in the respiratory tree [46]. Unlike all these infection routes, SARS-CoV-2 infection may also possible with the hematogenous spread from the lacrimal gland [8].
Consequently, the human eye has three roles in coronavirus infection. Firstly, it is one of the target organs for coronavirus infection. Secondly, the conjunctiva can function as a transporter for human coronavirus to enter the respiratory tract. SARS-CoV-2 can reach to nasal mucosa with nasolacrimal epithelium, gastrointestinal tract, and systemic circulation by leaving the conjunctivitis [19]. Thirdly, conjunctival secretions and tears can function to spread human coronavirus [52].
4. SARS-CoV-2 related ocular manifestations
4.1 Ocular surface manifestations
Since ocular surfaces hold the potential for SARS-CoV-2 transmission, clinical research focusing the COVID-19-associated ocular symptoms have attracted great attention. Even though, the incidence of SARS-CoV-2 infection through ocular surfaces is low, ocular manifestations are various. Dry eyes, epiphora, hyperemia were the most prevalent symptoms in COVID-19 patients, while chemosis, photophobia and conjunctivitis are barely seen. Other reported ocular surface symptoms were conjunctival congestion, conjunctival secretions, foreign body sensations, blurred vision, itching/irritation, ocular pain, and eye redness. The prevalence of SARS-CoV-2 and profiling ocular symptoms related to COVID-19 are summarized in Table 1 by including 2660 patients from 43 independent studies [10, 11, 12, 13, 14, 16, 17, 59, 60, 61, 69, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108].
In a large study, including 535 patients, 5.0% of the patients (27 patients) displayed conjunctival congestion. Conjunctival congestion was in fact, the first symptom in four patients, which explains that ocular manifestations may be observed in early times of SARS-CoV-2 infection. However, SARS-CoV-2 nucleic acid could not be identified in ocular swabs. Other ocular manifestations were dry eye, blurred vision, foreign body sensation, tearing, itching, ocular pain and photophobia. Conjunctival congestion has lasted for 5.9 ± 4.5 days among the patients and ofloxacin, tobramycin and ganciclovir eye drops were supplied for treatment. Conjunctival congestion was a more widespread symptom in patients with frequent hand-eye contact [10].
In some studies, the presence of SARS-CoV-2 viral RNA on the ocular surfaces was confirmed. In February 2020, a study including 30 COVID-19 patients has declared SARS-CoV-2 nucleic acid in tear, conjunctival secretion as well as in sputum samples in one patient with conjunctivitis at the third day of the disease. The presence of the virus in the eye allowed speculation that transmission with the aerosols could be possible. However, this was one of the early studies and at that time there was not enough information about the transmission routes of virus [104]. In another study, involving 72 COVID-19 patients, conjunctivitis was detected in two patients (2.8%) and SARS-CoV-2 nucleic acid was identified in ocular discharges of one patient [106]. Detection of virus RNA in the eye suggests that the ocular pathway may be a gateway for viral transmission. In a case study, SARS-CoV-2 RNA was detected on the ocular swab of a woman with conjunctivitis at the third day of the COVID-19 diagnosis. Conjunctival samples were continuously taken on a daily basis and viral RNA was detected, despite in a decreasing curve for 21 days. However, the viral RNA became observable again 5 days after it became unobservable in the ocular swabs. To understand the presence of viral replication in the conjunctiva, researchers have inoculated the first positive viral RNA samples in Vero E6 cells and 5 days later, they have observed cytopathic effect and confirmed viral replication by RT-PCR with RNA purified from Vero E6 cell growth media [83].
On the other hand, SARS-CoV-2 viral RNA was also present in some patients without conjunctivitis. Viral RNA was detected in ocular swabs in two patients among 33 COVID-19 patients (6.1%) without any ocular manifestation [19]. In another study, including 121 patients diagnosed with COVID-19, ocular manifestations such as itching, tearing, redness, foreign body sensation and discharge were obtained in only eight patients (6.6%). Ocular swab was positive for SARS-CoV-2 RNA in one of them and in two patients without ocular manifestations [107]. The presence of SARS-CoV-2 on normal ocular surfaces may indicate that both symptomatic and asymptomatic ocular surface contact also has a risk of virus transmission.
There are several cases, where ocular manifestations were reported as the first presenting manifestation of COVID-19. A 65-year-old patient applied to ophthalmology department with a complaint of burning sensation and discharge for the last two days was diagnosed with conjunctivitis. After 2 days, the patient was admitted to the hospital with symptoms associated with COVID-19 and SARS-CoV-2 infection was confirmed with positive RT-PCR results of the nasopharyngeal and conjunctival swabs as well as computed tomography (CT) scanning of the lungs [88]. In a study, 12 out of 38 COVID-19 patients (31.6%) presented ocular symptoms, including conjunctivitis, hyperemia, epiphora, chemosis and increased secretions. SARS-CoV-2 nucleic acid was detected in conjunctival swabs of two patients. In these patients, conjunctivitis was the first symptom in one patient [11]. The occurrence of ocular symptoms primarily suggests that ocular surface is the potential transmission site of the virus in these patients.
Conjunctivitis could be seen in both early and late stages in the course of COVID-19. In February 2020, bilateral conjunctivitis, including redness, tearing and foreign body sensation was observed 13 days after the onset of the disease in a COVID-19 patient. Although the presence of SARS-CoV-2 nucleic acid was less in the nasopharyngeal and sputum swabs, it was confirmed in conjunctival swabs by RT-PCR at days 13, 14 and 17 in a gradually decreasing manner. Ribavirin eye drops helped the treatment of the symptoms and the RT-PCR test from ocular swabs turned negative on day 19 [82]. In a COVID-19 patient at intensive care unit, ocular symptoms started on the 17th day of the disease with conjunctival hyperemia and clear secretions and pseudomembranous. On the 19th day, hemorrhagic conjunctivitis was defined, however, SARS-CoV-2 RNA was not detectable in the patient’s conjunctival and tear samples. Azithromycin eyedrop and dexamethasone were used for treatment and ocular manifestations were started to decrease from day 21 [95]. Conjunctivitis, seen in the middle and late phases of the COVID-19, may have developed due to systemic viral infection or auto-inflammatory and autoimmune responses. Considering the nasolacrimal duct forms a connection between the eye and the respiratory tract; it is likely that the virus in the respiratory tract may subsequently infect the eye. The fact that ACE2 receptor is expressed predominantly in the respiratory tract than epithelial cells in the eye surface confirms this theory.
In the first study where keratoconjunctivitis was reported as the main symptom of COVID-19, virus was detected in ocular swabs with much lower titers than respiratory swabs. The corneal findings in this case involved pseudodendrite, subepithelial infiltrate and multiple epithelial defects spreading through the cornea [81]. The first case of COVID-19 related acute anterior uveitis associated with acute follicular conjunctivitis and conjunctival hyperemia was reported in Italy. Acute anterior uveitis was characterized by bilateral eye redness lasting two weeks, unilateral photophobia, lacrimation, miosis, aqueous humour flare and anterior lens opacity causing blurred vision [16].
The low rate of ocular symptoms seen in patients with COVID-19 may be due to the under diagnosis. Particularly, for the diagnosis of conjunctivitis, an ophthalmologist is required. Otherwise, disease can be unnoticed and treated silently during systemic COVID-19 treatment regimen. Besides, since the ocular inoculation of SARS-CoV-2 cannot be fully elucidated, sampling time in the course of disease may also be a factor affecting detection of the presence of the virus on ocular surfaces. Since the virus may have been eliminated by ocular defense mechanisms or may have already entered the respiratory tract, the duration time of the virus on ocular surfaces may be very short. The sensitivity threshold of RT-PCR, which is the conventional method used to confirm the presence of the virus, may also cause false negative results. However, in order to declare that conjunctivitis occurs due to SARS-CoV-2 infection, virus detection through ocular swabs is mandatory since conjunctivitis may be of different viral, bacterial and allergic origin in patients with COVID-19. It should also be taken into account that ocular manifestations may be the only symptoms of the COVID-19.
4.2 Retinal findings in patients with COVID-19
In viral infections, the cytopathic effect of the viral agent on retinal cells or damage to the retinal vasculature are common pathological findings of the retina. Systemic damage caused by SARS-CoV-2 made it necessary to enlighten additional viral involvement sites in addition to the respiratory system. Presence of ACE2 in aqueous humor [7] and retina [15] has allowed researchers to raise query on the possible injury caused by COVID-19 in the posterior part of the eye.
The first report published in May 2020 declaring COVID-19 related retinal alterations has paved the way for further studies. Retinal cotton wool spots and microhemorrhages in four patients as well as hyperreflective lesions at ganglion cell layer and inner plexiform layer in 12 patients was reported. Of the 12 patients, three had high blood pressure, one had diabetes and one had dyslipidemia. Examination was performed on 11–33 days after the onset of COVID-19 symptoms using optical coherence tomography (OCT). Intraocular inflammation was not noticed in any of the patients, however the presence of SARS-CoV-2 in the intraocular fluids was not tested in this study [14]. Similarly, in another study, 10 out of 18 intensive care unit patients had retinal abnormalities characterized by cotton wool spots, flame-shaped hemorrhages, peripheral retinal hemorrhages, macular hemorrhages, retinal pigment epithelium hyperplasia and choroidal naevus. Nine of them had a history of diabetes and 12 of them had high blood pressure [96]. In another study of 25 patients, 3 patients (12%) displayed retinal changes including microhemorrhages, flame-shaped hemorrhage and nerve fiber layer infarcts (Figure 3). Retinal examinations were performed at 12–59 days after the onset of symptoms and only one patient had a medical history of hypertension. Another patient had hypotension, severe anemia, kidney and peripheral nervous system damage, which may explain microhemorrhages and nerve fiber layer infarcts [89]. These findings suggest that retinal alterations may occur depending on the patients’ medical histories, yet it may also be due to the cytokine storm, which is developed as a result of immune response induced by COVID-19 and reaches to the retina by passing through the blood retina barrier.
Figure 3.
Retinal photograph of a patient with COVID-19. (A) Nerve fiber layer infarct above the optic nerve head, and microhemorrhages in the papillomacular bundle close to the optic disc was present in the right eye. (B) Nerve fiber layer infarcts at the inferior temporal vascular arcade, approximately 1.5-disc diameters inferior to the macula was present in the left eye. Reproduced from Reference [89] (CC BY 4.0).
In the fundus examination of a COVID-19 patient who was admitted to the hospital with the complaint of scotoma and decreased vision in one eye, fern-like retinal whitening, hyperreflective inner layers, increased venular tortuosity and retinal hemorrhages were found in the right eye and the patient was diagnosed with impending central retinal vein occlusion (iCRVO). After 10 days of treatment with steroids, patient’s retinal changes and blood flow in central retinal vein almost returned to normal [87]. The iCRVO in this patient is thought to be due to the systemic response of COVID-19, as it can be treated with steroid therapy and the patient has no risk-bearing medical history. In the examination of a patient with lower leg pain and blurred vision in addition to common COVID-19 symptoms, deep venous thrombosis in the leg, bilateral CRVO, intraretinal hemorrhages, optic disk swelling, and cotton wool spots were detected. After 2 weeks of anticoagulant treatment, the patient’s complaints returned to normal [12]. Similar to this, vascular occlusions may occur in the cases of hypertension, obesity and high cholesterol. In another study, bilateral cotton wool spots were detected on fundus examination during the late stage of COVID-19 in one patient, suffering an arcuate visual field defect in one eye. It was the first study to report COVID-19 induced vision loss. Retinal microvascular ischemia in the superficial plexus, which corresponded to the arcuate scotoma was detected by optical coherence tomography (OCT) angiography [17]. These retinal changes can be related to microangiopathy and ischemia that are characterized in different anatomic parts in COVID-19 pathogenesis [109, 110].
In a study involving 54 COVID-19 patients, 15 patients had dilated veins, tortuous vessels was observed in seven patients, retinal hemorrhages in five patients, cotton wools spots in four patients and drusen in six patients were reported during fundus examination. Both mean artery diameters for severe cases and mean vein diameters for severe or non-severe cases were significantly higher in 54 COVID-19 patients, compared to 133 unexposed subjects [13]. Retinal vessel diameters and retinal circulation are parallel to the systemic circulation. Alterations in the retinal vessels can provide an insight into alterations in other organs. Enlargement of the vessels can be explained by the increased blood supply and effect of inflammatory mediators together with the inflammatory response to COVID-19 or a direct effect of the SARS-CoV-2 to endothelium. Moreover, two patients with COVID-19 had paracentral acute middle maculopathy and acute macular neuroretinopathy accompanied by scotoma [60]. In another study, scotoma, acute vision loss and several retinal hemorrhages related with acute macular neuroretinopathy and paracentral acute middle maculopathy were reported in one patient [61]. It has been reported that paracentral acute middle maculopathy is associated with the reduced blood supply to intermediate, deep, superficial capillary plexuses and acute macular neuroretinopathy is associated with the reduced blood supply to deep capillary plexus [111].
Venous thromboembolism is also a reported condition in COVID-19 patients; however, it is not known whether this is caused by the direct effect of the virus or the inflammatory response of the COVID-19. Cotton wool spots are characterized by disruption of axoplasmic flow in nerve tissue layer due to microvascular occlusion, and retina is extremely sensitive to ischemic events in the body. Considering the thrombotic conditions caused in COVID-19 patients, it can be thought that cotton wool spots in the retina are a result of the occlusion of terminal retinal arterioles.
The fact that the SARS-CoV-2 affects the central nervous system [112, 113] and the presence of its nucleic acid in retina [114] suggests that as a part of central nervous system, retina may be directly affected by the virus. Considering that the effect of SARS-CoV-2 on the central nervous system also effects the vital organ brain, non-invasive retinal examinations could be a prediction of the scope of COVID-19 in other organs like brain and heart, which has been implemented before for different diseases such as stroke, Alzheimer disease, multiple sclerosis and Parkinson disease [115].
In some studies, there was no link between retinal findings and ocular surface changes suggesting that retinal findings may be a marker of systemic alterations, and thus the importance of fundus examination should not be underestimated even in patients without any ocular complaints during the COVID-19 pandemic.
4.3 COVID-19 related expected long-term effects on eye
Ocular manifestations of COVID-19 range from redness to acute anterior uveitis on the anterior segment of the eye and from microhemorrhages to retinal microvascular ischemia on the retina. Some of these manifestations may cause vision loss and blurred vision.
Retinal changes such as damage of retinal cells or retinal vasculature may be the precursor of a long-term retinal disease. When the peripapillary vascular impairment is compared between the control group and patients recovered from COVID-19, lower radial peripapillary capillary plexus perfusion density and reduced blood supply to peripapillary retinal nerve fiber layer were present in post COVID-19 patients [98]. Older and systemic hypertensive patients were more prone to this microvascular damage. The radial peripapillary capillary plexus is very important for function of the retinal ganglion cells and axons and it is related to nerve fiber layer thickness and visual field loss in glaucoma [116]. Decrease in radial peripapillary capillary plexus density and nerve fiber layer thinning have been characterized in patients with early stage of glaucoma [117, 118]. Besides, it is more prominent in patients with glaucoma for more than ten years than in patients with glaucoma less than ten years [119]. However, whether the peripapillary capillary changes in patients with COVID-19 are reversible will be seen in further studies. Although these patients are at risk of developing glaucoma in the future, it should be kept in mind that there are several effective physiological parameters for disease development.
Looking at MERS and SARS outbreaks, it is difficult to predict the long-term ocular effect of COVID-19, due to the insufficient ocular findings and limited number of patients. Although different mechanisms cause the ocular effects of coronaviruses in animals, studies in animal models and understanding these mechanisms could give an idea about the long-term ocular effects of coronavirus in humans. Investigation of the effect of the coronavirus-related immune responses in retinal disease using experimental coronavirus retinopathy (ECOR) model indicated that levels of some cytokine molecules (TNF-α, TNF receptors) and signaling molecules (nitric oxide) increased in mice infected with murine coronavirus (mouse hepatitis virus) [120]. It was stated that TNF-α induction of nitric oxide may cause retina degeneration and loss of photoreceptor cells. In addition to that, following the primary immune response to virus, increased TNF receptor molecules and T cell reactivity may trigger autoimmunity.
The RAS system and its component ACE2 have important regulatory functions in the eye. ACE2 activation is known to reduce intraocular pressure [36]. Decreased expression of ACE2 to prevent viral spread can lead to misbalance of ACE-Angiotensin II/ACE-Angiotensin (1–7) balance, increase in intraocular pressure, vasoconstriction [61] and subsequently cause glaucoma. Hypothetically, in the light of this information, it is difficult to say that COVID-19 can cause a medium- or long-term serious ocular diseases such as glaucoma. However, ocular follow-up of COVID-19 patients with retinal symptoms may present whether these assumptions are justified as well as may benefit understanding virus tropism and immune responses to the virus.
5. Conclusion
With the emergence of SARS-CoV-2 in December 2019, the reporting of ocular symptoms observed in COVID-19 patients attracted many researchers and numerous publications were published in a short time to clarify the interaction between SARS-CoV-2 and the eye. Despite the fact that ocular symptoms present a low prevalence relative to respiratory and systemic symptoms, there is strong evidence for the ocular transmission of the SARS-CoV-2. The eye surfaces are one of the primary infection sites for SARS-CoV-2 and conjunctival secretions and tears can cause systemic spread of the virus. Additionally, the virus can use the ocular surfaces as a gateway to the respiratory tract.
Revealing the relationship between coronaviruses and the eye is of great importance in the diagnosis, treatment and infection control in both present and potential viral infections. Although many studies are investigating the ocular tropism of respiratory viruses, ocular transmission routes should be better understood in order to develop novel treatment methods such as antiviral agents that can be used in ocular treatments against RNA viruses. Besides, non-invasive retinal examinations can be evaluated as a reflection of the patients’ current systemic thrombotic condition and can be used in long-term patient follow-up related to COVID-19.
Considering that the first or only symptom of the COVID-19 may be conjunctivitis and virus can spread via tears even from asymptomatic patients, ophthalmologists and healthcare professionals should be aware of the risk and take necessary precautionary measures.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"COVID-19, SARS-CoV-2, conjunctivitis, conjunctiva, retina, ACE2, TMPRSS2",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/76171.pdf",chapterXML:"https://mts.intechopen.com/source/xml/76171.xml",downloadPdfUrl:"/chapter/pdf-download/76171",previewPdfUrl:"/chapter/pdf-preview/76171",totalDownloads:274,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:2,introChapter:null,impactScore:0,impactScorePercentile:34,impactScoreQuartile:2,hasAltmetrics:1,dateSubmitted:"December 11th 2020",dateReviewed:"March 5th 2021",datePrePublished:"April 8th 2021",datePublished:"October 27th 2021",dateFinished:"April 8th 2021",readingETA:"0",abstract:"The current COVID-19 pandemic has affected more than 100 million people and resulted in morbidity and mortality around the world. Even though the disease caused by SARS-CoV-2 is characterized by respiratory tract involvement, previous and recent data also indicates ocular manifestation. Not surprisingly, cell entry point of the virus, ACE2 receptor, is widely expressed in ocular tissues ranging from conjunctiva to retina. Despite the sensibility of ocular tissues, the sophisticated defense mechanism of the eye might eliminate viral transmission. Nevertheless, the potential of systemic transmission through the nasolacrimal duct may not be eliminated. In the case of ocular involvement, the disease outcomes might be as treatable as conjunctivitis or as serious as retinal degeneration and the treatment regimen vary accordingly. Within these contingencies, our aim with this chapter is to shed light on molecular bases of SARS-CoV-2 infection, systemic invasiveness following ocular transmission, manifestation and permanent effects on ocular tissues.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/76171",risUrl:"/chapter/ris/76171",book:{id:"10345",slug:"infectious-eye-diseases-recent-advances-in-diagnosis-and-treatment"},signatures:"Saliha Durak, Hande Eda Sutova, Abuzer Alp Yetisgin, Ozlem Kutlu and Sibel Cetinel",authors:[{id:"341355",title:"Ms.",name:"Saliha",middleName:null,surname:"Durak",fullName:"Saliha Durak",slug:"saliha-durak",email:"salihadurak@sabanciuniv.edu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Sabancı University",institutionURL:null,country:{name:"Turkey"}}},{id:"344048",title:"Assistant Prof.",name:"Sibel Çetinel Çetinel",middleName:null,surname:"Çetinel",fullName:"Sibel Çetinel Çetinel Çetinel",slug:"sibel-cetinel-cetinel-cetinel",email:"cetinel@sabanciuniv.edu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Sabancı University",institutionURL:null,country:{name:"Turkey"}}},{id:"344052",title:"Dr.",name:"Ozlem",middleName:null,surname:"Kutlu",fullName:"Ozlem Kutlu",slug:"ozlem-kutlu",email:"ozlemkutlu@sabanciuniv.edu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Sabancı University",institutionURL:null,country:{name:"Turkey"}}},{id:"347787",title:"MSc.",name:"Hande Eda",middleName:null,surname:"Sutova",fullName:"Hande Eda Sutova",slug:"hande-eda-sutova",email:"esutova@sabanciuniv.edu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Sabancı University",institutionURL:null,country:{name:"Turkey"}}},{id:"347789",title:"MSc.",name:"Abuzer Alp",middleName:null,surname:"Yetisgin",fullName:"Abuzer Alp Yetisgin",slug:"abuzer-alp-yetisgin",email:"yalp@sabanciuniv.edu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Sabancı University",institutionURL:null,country:{name:"Turkey"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. ACE2 and TMPRSS2 expression profiles in ocular tissues",level:"1"},{id:"sec_3",title:"3. Potential systemic invasiveness of SARS-CoV-2 following ocular transmission",level:"1"},{id:"sec_3_2",title:"3.1 Natural ocular defense mechanisms",level:"2"},{id:"sec_4_2",title:"3.2 Nasolacrimal duct can play a role in SARS-CoV-2 systemic transmission",level:"2"},{id:"sec_6",title:"4. SARS-CoV-2 related ocular manifestations",level:"1"},{id:"sec_6_2",title:"4.1 Ocular surface manifestations",level:"2"},{id:"sec_7_2",title:"4.2 Retinal findings in patients with COVID-19",level:"2"},{id:"sec_8_2",title:"4.3 COVID-19 related expected long-term effects on eye",level:"2"},{id:"sec_10",title:"5. Conclusion",level:"1"},{id:"sec_14",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Masters PS. The molecular biology of coronaviruses. Adv Virus Res. 2006;66:193-292.'},{id:"B2",body:'Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. 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Chin J Exp Ophthalmol. 2020;38(03):242-4.'},{id:"B106",body:'Zhang X, Chen X, Chen L, Deng C, Zou X, Liu W, et al. The evidence of SARS-CoV-2 infection on ocular surface. The Ocular Surface. 2020;18(3):360-2.'},{id:"B107",body:'Zhou Y, Duan C, Zeng Y, Tong Y, Nie Y, Yang Y, et al. Ocular Findings and Proportion with Conjunctival SARS-COV-2 in COVID-19 Patients. Ophthalmology. 2020;127(7):982-3.'},{id:"B108",body:'Zhou Y, Zeng Y, Tong Y, Chen C. Ophthalmologic evidence against the interpersonal transmission of 2019 novel coronavirus through conjunctiva. medRxiv; 2020.'},{id:"B109",body:'Danzi GB, Loffi M, Galeazzi G, Gherbesi E. Acute pulmonary embolism and COVID-19 pneumonia: a random association? Eur Heart J. 2020;41(19):1858.'},{id:"B110",body:'Iba T, Levy JH, Levi M, Connors JM, Thachil J. Coagulopathy of Coronavirus Disease 2019. Critical Care Medicine. 2020;48(9):1358-64.'},{id:"B111",body:'Chen Y-C, Chen S-N. Microvascular change in acute macular neuroretinopathy by using optical coherence tomography angiography. Taiwan journal of ophthalmology. 2019;9(2):118.'},{id:"B112",body:'Pryce-Roberts A, Talaei M, Robertson N. Neurological complications of COVID-19: a preliminary review. Journal of Neurology. 2020:1.'},{id:"B113",body:'Paniz-Mondolfi A, Bryce C, Grimes Z, Gordon RE, Reidy J, Lednicky J, et al. Central nervous system involvement by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Journal of medical virology. 2020;92(7):699-702.'},{id:"B114",body:'Casagrande M, Fitzek A, Püschel K, Aleshcheva G, Schultheiss H-P, Berneking L, et al. Detection of SARS-CoV-2 in Human Retinal Biopsies of Deceased COVID-19 Patients. Ocular Immunology and Inflammation. 2020:1-5.'},{id:"B115",body:'London A, Benhar I, Schwartz M. The retina as a window to the brain—from eye research to CNS disorders. Nature Reviews Neurology. 2013;9(1):44.'},{id:"B116",body:'Mammo Z, Heisler M, Balaratnasingam C, Lee S, Yu D-Y, Mackenzie P, et al. Quantitative Optical Coherence Tomography Angiography of Radial Peripapillary Capillaries in Glaucoma, Glaucoma Suspect, and Normal Eyes. American Journal of Ophthalmology. 2016;170:41-9.'},{id:"B117",body:'Mansoori T, Sivaswamy J, Gamalapati JS, Balakrishna N. Radial peripapillary capillary density measurement using optical coherence tomography angiography in early glaucoma. Journal of glaucoma. 2017;26(5):438-43.'},{id:"B118",body:'Jia Y, Simonett JM, Wang J, Hua X, Liu L, Hwang TS, et al. Wide-Field OCT Angiography Investigation of the Relationship Between Radial Peripapillary Capillary Plexus Density and Nerve Fiber Layer Thickness. Investigative Ophthalmology & Visual Science. 2017;58(12):5188-94.'},{id:"B119",body:'Sefic S, Kasumovic A, Matoc I, Halimic T, Voloder B, Muhamedagic L, et al. Assessment of Perfused Peripapillary Capillaries and Peripapillary Capillary Density Maps in Glaucoma Patients. Med Arch. 2020;74(4):275-8.'},{id:"B120",body:'Hooper LC, Chin MS, Detrick B, Hooks JJ. Retinal degeneration in experimental coronavirus retinopathy (ECOR) is associated with increased TNF-α, soluble TNFR2 and altered TNF-α signaling. Journal of Neuroimmunology. 2005;166(1):65-74.'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Saliha Durak",address:null,affiliation:'
Nanotechnology Research and Application Center (SUNUM), Sabanci University, Turkey
Faculty of Engineering and Natural Sciences, Molecular Biology, Genetics and Bioengineering Program, Sabanci University, Turkey
Nanotechnology Research and Application Center (SUNUM), Sabanci University, Turkey
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1. Introduction
Population aging is one of the most evident demographic phenomena around the world. The United Nations (UN) estimates that the number of people aged 60 and over will double by 2050 and triple by 2100 (corresponding to 3.1 billion people) [1]. This age group is considered one of the most vulnerable in society, particularly affected by poverty, illness, and social isolation [2], and it is often studied as a homogeneous group when there are several factors that distinguish older individuals (age, education level, family context, income, physical and mental health conditions, mobility level, technological capacity, etc.) [3].
In this sense, spatial planning and service networks must be adapted in advance according to the long-term demographic projection and based on a deep knowledge of the current reality, being extremely important to confront the needs of the population and the response capacities of the territories and services [4].
This study focuses on the debate about the walking accessibility to primary health services by the older in the Lisbon Metropolitan Area (LMA), in Portugal, for healthy and age-friendly environments since the level of proximity to services and the ability to reach them are fundamental to promote a healthier aging and greater equity in and among communities. The study presents three research questions (RQs):
RQ1) Is the location within the LMA a differentiating element of walking accessibility to primary health services (PHS) and hence an inequity factor?
RQ2) Do the olders demand for PHS consistent with what is expected to have in age-friendly environments?
RQ3) What kind of solutions are implemented in LMA to promote a more equitable access to PHS by the olders?
The study combines several approaches. We seek to identify possible constraints to equity based on the accessibility to health services: (i) the potential of walking accessibility generated by network analysis recurring to geographic information systems and using adapted criteria to the older community; (ii) the actual demand patterns of the olders gathered from an applied survey in LMA; and (iii) the identification of solutions at local, municipal, and metropolitan levels in the LMA and energized by local authorities, health services, nongovernmental organizations, or social institutions to minimize inequity situations.
The chapter is organized into six parts: Section 1 respects to the introduction and is followed by a theoretical rationale centered on walking accessibility to primary healthcare by the older people in Section 2, and the presentation of the methodology and case of study in Section 3. The discussion of the results based on the confrontation between the supply and demand approaches of primary health services by the olders in LMA is presented in Section 4, and some initiatives that minimize the identified constraints in LMA are addressed in Section 5. The chapter ends with the main conclusions (Section 6).
2. Accessibility to healthcare services for age-friendly environments
The rapid aging of the world population is considered one of the major global challenges. On the one hand, it is seen as a positive phenomenon insofar as it represents social, economic, and biomedical progress due to generalized better feeding, personal hygiene, healthcare, and housing conditions, among many other aspects. On the other hand, it reflects a demographic trend that combines increasing life expectancy and falling fertility rates [5]. In the long term, and related to a time of growing urban population, this phenomenon will bring an overload of the social and health systems, among other services and infrastructures, and the need to readjust them [4, 6]. In a larger level, this will affect the regional competitiveness and make the social and territorial cohesion difficult. This is based on the perspective that the older population will, at some point, become more dependent on society and greater demanders in terms of physical and/or mental healthcare and supportive care [7]. On the other hand, their moving limitations could promote social isolation and a strong feeling of loneliness, considered by the Joint Research Center as a public health issue with negative impacts on community trust, social cohesion, and economic growth [8, 9].
However, it is a mistake if we consider that all people over the age of 65 have the same characteristics and needs, and that remains the same over time. Given the conditions of the modern world, in Europe, as in other World regions, we are witnessing the existence of a group of older people who are more active, qualified, informed, socially participatory, mobile, technological, and demanding in the cultural and recreational domain [10, 11]. To respond to these demands, their living spaces have expanded from the local to the regional/metropolitan level [12]. On the other hand, the increase in average life expectancy is reflected in the existence of individuals with diversified health conditions, namely about disease prevalence and different physical and mental conditions, influenced by the natural aging process, genetics, lifestyle, and the surrounding environment [13].
In the quest to keep the olders as an active part of society, with good health and well-being levels until as late as possible, adaptations in the urban environment of communities and cities must compensate the physical, mental, and social changes associated with aging. Operationally, this is observed in the guidelines promoted by institutions such as the United Nations and the World Health Organization (WHO) and reflected in the naming of this decade as “The United Nations Decade of Healthy Aging (2021-2030)” [14], with a view to improve the lives of older people, their families, and the communities in which they live.
In urban planning, the “Age-friendly Cities and Communities,” that is, “(…) places that actively involve, value, and support older adults, both active and frail, with infrastructure and services that effectively accommodate their changing needs,” is one of the most widespread urban models ([15], p. 1). Simultaneously, Age-friendly Cities and Communities is an initiative of the WHO, started in 2006, to support active and healthy aging at local level. “Housing,” “Social participation,” “Outdoor spaces and buildings,” “Transportation,” and “Community support and health services” are some of the focused topics [4].
In this model, as in others as “sustainable communities,” “healthy cities,” or the “15-minute city,” the principle of proximity is fundamental [16, 17]. Proximity refers to the distance (physical or not) and/or distance time to the different destinations where individuals live: workplace, various services, goods and equipment, public spaces, green spaces, commercial areas, cultural spaces and leisure; but also to the network of contacts: family, friends, or other social networks. The proximity to people and living areas as a way of satisfying individual needs are enhancers of a greater quality of life and well-being, active participation in society, maintenance of the practice of physical and mental activity, and greater autonomy [18]. Despite the studies regarding the concept of proximity (e.g., 15-minute walking, radius distance of 500 meters, etc.), this is conditioned by the ability and perception of individuals, especially when we refer to the older community, where part of it has age natural mobility constraints.
The principle of proximity as a factor of an age-friendly, healthy, inclusive, and sustainable environment leads us to the promotion of a walkable environment, and this is an environment based on active transport modes, namely the walking in and around the community, to enhance, simultaneously, an equitable accessibility to all destinations and a positive physical activity engagement [19]. This discussion requires a double understanding about (1) the relationship between urban mobility, particularly in the older people context, and the built environment; and (2) the characteristics and specificities of each community [20].
Hence, recent research promotes an holistic perspective that relates the social and physical environments, recurring to digital tools and services, to promote better health, independent living, active participation, and more equity. See, for example, the SHAFE project results [21, 22] that present the community level as the physical, social, and cultural ecosystem closest to the people and their daily lives.
The mobility of all, as the ability to meet the needs to move freely [23], is one of the challenges that cities have for pursuing social and civic life, participation in community activities, the development of a sense of belonging, and to promote health and well-being through the possibility of accessing health services, green spaces, commercial areas, leisure and cultural spaces, etc. [24]. Hence, it is utmost important to consider that the cognitive and motor skills of olders deteriorate over time, affecting their mobility [25]. This is reflected in constraints on walking speed, the ability to freely drive or use public transport, the increase in falls and the feeling of insecurity when walking on the street, and constraints that, at the limit, avoid carrying out their daily lives autonomously [26].
Mobility is also a reflection of a mutual interaction between the built environment and olders` behavior, insofar the organization of the physical and functional components of urban system generates the opportunities for movement in the context of urban life. Thus, the configuration of the urban system must be adapted to the needs of the elderly [27]. This interaction raises the importance of thinking about improving urban accessibility, that is, the ability of an individual to reach a certain place, through a certain transport mode and in a certain time. This requires a relational reading between the conditions of transport infrastructure networks (and the ease of travel in terms of distance and time), the location of activities and services of general interest proximity between services and users), and the characteristics and needs of users [27, 28, 29].
As health is a universal right, the planning of public health services must consider three fundamental principles [30], which sometimes collide. The first concerns the “Equity in service provision,” represented by the equal access to healthcare for people in equal need. This premise is related to the notions of spatial fairness and spatial justice that considers the geographical context as an influencing factor. The second is the “Effectivity of health services,” balancing the real health benefits and the resources management. The last is the “Efficiency of health services” maximizing the health benefits and minimizing the costs of provision.
Focusing on the health services at the local level, Primary Health Care (PHC) is the first contact between the individual and the health system, as it “provide complete care to people, according to their health needs throughout their lives and not only for a set of specific diseases. (…) ensure that people receive comprehensive care, from promotion and prevention to treatment, rehabilitation and palliative care, as close as possible to their daily environment.” [31, n.p.]. It is stated that a PHC-based health system allows for greater efficiency of more specialized care (e.g., hospital care), lower hospitalization rates, and reduced individual and government health expenditures [31].
A primary health service with positive impact on health, quality of life, and well-being should present good levels of access [4], considering several demand factors: availability and diversity of health services, frequency of use, individual and family factors, physical and social environment, among others [32, 33]. Over time, several studies addressed this topic [28, 29, 33, 34, 35, 36], combining the approaches of health service providers and users, reflected in the following principles:
Availability, as the existence, quantity, and maximum capacity of the services;
Accessibility, associated with the physical proximity between services and users and the ease of travel to them in terms of distance, time, and transportation modes;
Affordability, related to the costs for users;
Adequacy, in terms of service organization and convenience for the user (waiting time, ease of dealing);
Acceptability, represented by the trust and satisfaction with the services by the users;
Knowledge, articulating the communication and dissemination of knowledge by users, health professionals, and others.
Accessibility to health services arises the need of a multisectoral and multilevel approach, in this case related, for example, to the healthcare network, mobility and accessibility, and demographic characteristics in each territory as they are influencing factors of healthcare inequalities [36]. Among other methodologies, the levels of physical accessibility of each service could be evaluated recurring to geographic information system (GIS) [17, 23, 32, 33, 36]. Here, it is possible to model the respective service catchment area in a certain distance and/or distance time, based on the various transport modes or their combination. Service catchment areas allow to quantify the total area and served population within the proposed thresholds (e.g., within 15-minute walking in a determined speed); to identify worse served communities, and hence more vulnerable; and to relate it to context indicators in the social, economic, and territorial domains [29, 36, 37]. This analysis is also a potential support element for the restructuring of the service networks through the identification of new service positioning for better population and territorial coverage rates [38], to adapt the transport system in order to promote better accessibility level, or even to support the design of innovative, flexible, and informal solutions promoted by various stakeholders [22].
3. Methodological steps and case study framework
The methodology of this study followed three steps (Figure 1), in order to answer the research questions.
Figure 1.
Methodological steps of the research.
Step 1 involved a literature review, not only for thematic framing of the mobility conditions of the older people and their specific constraints (e.g., pedestrian speed), but also for the identification of the main methodologies and accessibility indicators, specifically adapted to the olders.
Step 2 refers to the application of the assessment of walking accessibility to primary healthcare from the perspective of the older people in the case of the Lisbon Metropolitan Area, Portugal. LMA is spread over by 18 municipalities, totaling 3015km2, and has a total population of 2,870,770 inhabitants, in 2021, and a population density of 952 inhab./km2. About 22% of LMA’s people are aged 65 or over (proportionally to the national figure of 23%) [39], unevenly distributed among the LMA, emerging a radioconcentric pattern, with higher older population densities in the parishes of the central areas (Lisbon & Ring 1 and Ring 2) and decreasing toward the peripheral areas (Ring 3 and Ring 4).
The population distribution is consistent with the urban occupation that presents the same radioconcentric pattern. The central metropolitan areas present a higher proportion of occupation, reflecting their urban/suburban and dense profile, while the peripheral areas present more dispersed urban occupations, reflecting the peri-urban occupation, except some urban continuum axes that grew along major road and rail axes (Figure 2).
Figure 2.
(a) Population density of older people (65+ years old); (b) land use in LMA—urban fabric. Source: [40, 41].
In Step 2.1., network analyses based on geographic information systems (GIS) allowed to visualize the service catchment areas of primary healthcare facilities and to quantify the served resident population, considering the geographic location of the equipment, the constraints of the transport network, and the characteristics of pedestrian mobility. The service areas were modeled, and the served population was calculated based on time-distance cutoffs of (i) until 15 minutes; (ii) 16–30 minutes; (iii) 31–60 minutes; and (iv) more than 60 minutes [32, 33, 36]. This approach considers two walking criteria: (a) average speed of the older people of 3.5 km/; and (b) average speed of disabled older people of 1.6 km/h [25, 36]. This step will answer to RQ1.
Step 2.2., related to demand, presents the results of a survey applied to the LMA population in 2017, including the older people. Based on the total sample of 403 families, with respect to 1004 individuals surveyed (for a Significance Level of 95% and a Margin of Error of 5%), we extracted the responses of 131 older adults from 111 families for this study. The total sample took into account the demographic distribution of the metropolitan population (age, sex, and family typology) and its geographic distribution considering the central area of Lisbon and its sequential four rings based on the distance to the Lisbon city (Figure 3). Such rings represent territories with urban land use profiles and, consequently, very different population densities, housing and services location, health services, and transport networks. This step will provide the answer to RQ2.
Figure 3.
LMA rings and the 11 parishes where the surveys were applied.
This survey collected information as: (i) the characterization of the respondents (age, income, family background, area of residence); (ii) the demand for primary healthcare services (location, frequency, travel mode, and time spent in the travel); and (iii) individual perceptions about personal health, safety, traffic, noise, and air pollution caused by transport in the residential area (as environmental factors). Hence, it was possible to discuss the results obtained in Steps 2.1. and 2.2., confronting the potential accessibility to primary healthcare services and the actual behavior of the surveyed older people.
Finally, Step 3 addresses some strategies to minimize older’s constraints to health accessibility in LMA, giving already implemented examples in three lines of action: (i) strategic plans oriented toward an healthy and inclusive aging; (ii) health services at home or in the proximity; and (iii) promotion of flexible transport to reach health services. This step answers to the RQ3.
4. Supply and demand of primary healthcare services of LMA’s older people
4.1 Supply approach to primary healthcare system in LMA
The last restructuring of the Portuguese health system dates from 2008, when the Constitutional Government recognized primary healthcare as a central pillar of the health system, published in the Decree-Law n° 28/2008, of February 22 [42]. One of the novelties was the creation of “groups of health centers” (ACES, in Portuguese Agrupamento de Centros de Saúde), with the function of providing primary healthcare to the population of a certain geographic area. Such geographic delimitation is related to geodemographic criteria (e.g., population structure, aging index, accessibility to the referral hospital), and with a population range between 50,000 and 200,000 residents.
The ACES have several functional units [42], namely:
Family Health Unit (USF—Unidade de Saúde Familiar), a unit providing healthcare to the group of users enrolled therein, with functional and technical autonomy;
Personalized Health Care Unit (UCSP—Unidade de Cuidados de Saúde Personalizados), a unit that provides personalized care in a given geographic area;
Community Care Unit (UCC—Unidade de Cuidados na Comunidade), providing healthcare, psychological and social support at home, especially to vulnerable individuals/families, in situations of risk or dependence, and in the area of health education and implementation of mobile intervention units;
Public Health Unit (USP—Unidade de Saúde Pública), a health observatory in the geographic area of ACES, for the elaboration of plans in the domain of public health, surveillance, management of intervention programs, and health promotion.
In January 2022, the network of Family Health Units (USF) and Personalized Health Care Units (UCSP), the most relevant functional units in the provision of healthcare, was widespread and complementarily distributed in the LMA, totalizing 225 units (153 USF and 72 UCSP) (Figure 4). Only 1.5% of the LMA surface and 0.5% of the population are not allocated to any of the USF/UCSP facilities.
Figure 4.
Location of USF and UCSP equipment by LMA ring, 2022: (a) family health units; (b) personalized health care units. Source: Based on [43].
Given their valences and functions, the studied health services have a limited schedule, but consistent with the law. The vast majority of services start at 8:00 am (94%), and the rest at 9:00 am, while the closing time is more diverse, between 4:00 pm and 8:00 pm, with a higher incidence at 8:00 pm (63%) and at 6:00 pm (22%).
Considering the proximity logic of primary healthcare services, it is desirable that the entire population has access to the equipment in which they are enrolled in a relatively short distance time, not forgetting that this indicator depends not only on the locations of the residence and equipment, but also by the selected transport mode. In the case of older people, it is important to approach car use based on the legal allowed speeds, but also the license possession and driving skills (factors influenced by the individual conditions of the users) [24]. Regarding walking mode is fundamental to consider the diversity of realities within the age group over 65 years old in terms of individual mobility ability, as this influences the walking speed (e.g., 3.5 km/h of regular pedestrian speed of an older person, 1.6 km/h on conditioned pedestrian speed cases) [32, 36].
Figure 5 demonstrates the accessibility level to healthcare services in the LMA, based on the representation of the service catchment areas of all equipment (USF and UCSP) by pedestrian mode conditioned to the aforementioned speeds, while the proportion of the surface and population covered by these service areas by ring is quantified in Table 1; and Appendix 1. In a scenario where the entire population of LMA travels in a walking speed of 4.5 km/h, then 65% of the population would reside within 15 minutes nearby health service. This proportion reduces to 57% if we consider only the olderly population, assuming a walking speed of 3.5 km/h, drastically reducing to 26% if we assume a walking speed of 1.6 km/h. A detailed analysis highlights three evidences (Table 1).
Figure 5.
Service catchment area of primary healthcare services (USF and UCSP) according to different time-distance cutoffs in all LMA (a) and (b) and zoomed in to the LMA Center (b) and (d); and different walking speeds: 3.5 km/h (a) and (b), and 1.6 km/h (c) and (d).
Walking speed of 3.5 km/h—Inhabitants with 65 or more years old
Until 15 min.
Until 30 min.
Until 60 min.
Inhab. (%)
Surface (%)
Inhab. (%)
Surface (%)
Inhab. (%)
Surface (%)
Lisbon & Ring 1
68.5
31.2
98.4
77.4
100.0
88.8
Ring 2
53.8
11.7
81.8
32.3
97.6
72.5
Ring 3
43.1
4.9
76.8
16.2
93.0
43.4
Ring 4
43.9
2.2
69.2
6.8
86.6
22.4
Total
56.8
5.8
86.2
16.3
96.3
37.6
Walking speed of 1.6 km/h—Inhabitants with 65 or more years old
Until 15 min.
Until 30 min.
Until 60 min.
Inhab. (%)
Surface (%)
Inhab. (%)
Surface (%)
Inhab. (%)
Surface (%)
Lisbon & Ring 1
33.0
9.7
63.8
27.6
96.9
72.8
Ring 2
22.7
3.3
49.2
10.3
79.0
28.6
Ring 3
17.8
1.3
38.6
4.2
73.1
14.0
Ring 4
23.0
0.6
41.7
1.9
65.5
5.8
Total
26.2
1.7
52.5
5.0
83.7
14.5
Table 1.
Inhabitants with 65 or more years old (%) and surface (%) covered by service catchment areas of primary healthcare services (USF and UCSP) according to different time–distance cutoffs (until 15 min., 30 min., and 60 min.) by LMA ring (absolute values available on Appendix 1). Source: own calculations based on BGRI [40] and service catchment areas calculated on network analysis function of ArcGis.
Firstly, the distribution of primary healthcare services (USF and UCSP) is in line with the urban system of the LMA, insofar as they are essentially located in the most densely populated areas [41]. This evidence comes from the higher percentage of population served at any time–distance limit in any ring compared with the percentage of covered area. For example, the served population at a distance time of 15 minutes at a walking speed of 3.5 km/h attends 69% in Lisbon & Ring 1 for only 31% of the covered territory. Keeping the criteria, in Ring 3 this situation is even more evident: 43% of the population served for only 5% of the ring surface. In LMA case, in the more peripheral Ring 3 and Ring 4 there are large unpopulated areas or with a very low population density, with land allocated to agricultural or forestry uses, for example.
This high complementarity between the urban system and the primary healthcare service system in the LMA could not happen in other metropolitan areas, highlighting the priority to study the served population by levels of distance time. Thus, the approach for urban planning should seek to increase the proportion of served population and respective conditions, rather than only focus to increase the served territory [33, 36].
Secondly, in the context of the LMA, is clear a ring differentiation in terms of walking accessibility to primary healthcare services. The central rings, closer to Lisbon, have better accessibility levels, which means that a greater proportion of older people lives close to the services. For example, 69% of the olders in Lisbon & Ring 1 and 54% in Ring 2 live within a 15-minute walking distance from the equipment (speed of 3.5 km/h), compared with 43% in Ring 3 and 44% in Ring 4. The same pattern is found in the constrained walking speed simulation (1.6 km/h): 33% in Lisbon and Ring 1, compared with 18% in Ring 3 and 23% in Ring 4.
This pattern is related to the socio-urban characteristics of each ring. In Lisbon and in the two following rings, there is a combination between a more concentrated urban occupation and a greater population density, thus generating a more numerous and spatially closer health facilities network, serving a larger number of residents in a short dispersed area. Thus, the proportion of residents and area served within 15-minute walking are higher than in the more peripheral areas (rings 3 and 4). These last rings present a more dispersed and mostly peri-urban occupation profile, although there is existence of some relevant urban areas especially nearby the major road and rail axes. In these areas, population is distributed between small urban concentrations where the main services are located and very low dense areas further away from small urban centers [28, 40, 41]. This increase the official service area allocated to each equipment to maintain criteria of resources` efficiency and the number of users according to the law [42].
Lastly, the differences in walking speeds are highly penalizing the relationship of proximity between health facilities and users, in particular for users who have mobility constraints such as the older people [19, 24]. We can observe this situation by comparing the served LMA’s older people up to 15-minute walking from a primary healthcare service: 57% when the walking speed is 3.5 km/h and 26% when the walking speed is 1.6 km/h.
Answering to RQ1, the results obtained raise a clear situation of inequity in the walking accessibility to the primary health services, penalizing the communities located in the most peripheral rings of the LMA, and particularly the age group of the olders, considering their pedestrian speed limitation (according to with the bibliography). This situation of inequity is further reinforced when the response of the public transport system in peripheral (and hence, more vulnerable) communities is also more limited in terms of network and service (fewer routes and less frequent service), when compared with the central areas of the LMA [12, 28].
This reading also highlights two aspects. Firstly, the importance of an analysis of accessibility indicators to health services considering the urban context [44], the settlement distribution, and the transport network, since a global analysis at the regional or metropolitan scale creates generalized ideas, insufficiently adequate to support the health service network planning in complementarity to the urban and transport systems, especially at the local level. This approach allows the discussion about inequity in a determined territory. Secondly, the need to compare the quantification of accessibility levels previously calculated using geographical modeling and the actual behavior of individuals, in this case those over 65 years of age, to validate whether better or worse walking accessibility to health services reflect real pedestrian displacements by these communities. Large discrepancies between potential and real walking accessibility must be studied in order to identify influencing factors (Section 4.2), as well as to support the design of flexible and/or informal solutions to minimize accessibility and access difficulties to health services (Section 5).
4.2 The demand for primary healthcare services in the perspective of older people in LMA
In addition to the analysis of primary healthcare service supply and its potential walking accessibility, we analyzed the real demand in the LMA through a survey applied to the metropolitan residents in 2017. The results give the real mobility patterns of residents to various activities, namely health services (in a pre-pandemic period). The search questioned the following: (i) the place where people seek such service (in the parish of residence, in the municipality of residence or in another municipality); (ii) the travel time to the destination; and (iii) the preferred transport mode(s).
The sample attends 111 families with older people that corresponds to 131 individuals over 65 years old. Single-person families (43%) are the most representative type of family, followed by couples of aged (26%), and other family types (18%), namely the coexistence of three generations or grandparents living with grandchildren. Around 63% of these aged families have an average monthly income of up to 1000 euro, 21% between 1000 and 1500 euro, and 17% of more than 1500 euro per month. About half of the older respondents affirmed to spend less than 30 euros a month on transport (48%), followed by families with costs between 30 and 60 euros (30%) and 60–150 euros (17%). It is also worth noting that half of the families with older people do not own any vehicle, 34% have one vehicle, and 15% have two vehicles (although the possession of vehicles in the family does not necessarily mean that the older individuals are their users as drivers, but could promote their use as passengers) [24].
Considering only individuals aged 65 or over (Table 2), it was observed that the demand for primary healthcare service is mainly based on short-term trips up to 15 minutes (60%), with a still relevant proportion of individuals who take 16–30 minutes (25%). The short duration of each trip also reflects the proximity to the desired destination, mostly in the residence parish (50%) or in another parish in the residence municipality (20%). A fifth of individuals travel to other municipalities, a phenomenon related to the proximity of health services to other moments of daily life (e.g., proximity to the workplace, family housing) or personal motivations and taste (e.g., preference for private services or for a specific doctor). Lastly, the use of individual motorized transport stands out (43%), followed by active modes (walking or cycling) (21%) and public transport (17%). In the LMA, carrying out short-term trips supported by the use of the car is observed not only to reach health services, but also to other goods and services and to school/employment, not only by the olders but also by all communities [23, 28].
Time-distance – Surveyed inhabitants with 65 or more years old
Until 15 min. (%)
16 to 30 min. (%)
More than 31 min. (%)
Total (%)
Lisbon & Ring 1
68.9
28.9
0.0
100
Ring 2
54.5
27.3
9.1
100
Ring 3
43.8
21.9
15.6
100
Ring 4
75.0
16.7
0.0
100
Total
59.5
25.2
6.3
100
Location—Surveyed inhabitants with 65 or more years old
Residence parish (%)
Residence municipality (%)
Other municipalities (%)
Total (%)
Lisbon & Ring 1
60.0
31.1
8.9
100
Ring 2
40.9
0.0
31.8
100
Ring 3
28.1
21.9
37.5
100
Ring 4
83.3
8.3
8.3
100
Total
49.5
19.8
21.6
100
Transport mode—Surveyed inhabitants with 65 or more years old
Soft modes (%)
Individual transport (%)
Public transport (%)
Various modes (%)
Total (%)
Lisbon & Ring 1
15.6
46.7
26.7
8.9
100
Ring 2
18.2
36.4
22.7
13.6
100
Ring 3
31.3
34.4
6.3
15.6
100
Ring 4
16.7
66.7
0.0
16.7
100
Total
20.7
43.2
17.1
12.6
100
Table 2.
Accessibility patterns to primary healthcare services (USF and UCSP) by older people by LMA ring.
Various realities relate the used transport mode to distance-time traveled emerged (Table 3). More than 4/5 of who use soft modes make short-term trips (up to 15 minutes) (87%). On the other hand, individual transport is the choice for short-term (74%) and medium-term trips duration (20%), that is, between 16 and 30 minutes. It should be underlined that the higher speed of this mode allows traveling a greater physical distance in the same period. In turn, those who use public transport are essentially to carry out medium-term trips (68%), while those who use various modes of transport are not strongly correlated with one specific time range, except the emphasis on trips of longer duration (more than 31 min.) (15%), compared with the other modes. These results are consistent with the general evolution of urban mobility from the community to metropolis level, increasing the diversity of living areas of individuals in their daily lives and the distance between the area of residence and such destinations, and hence arising new challenges related to the services and transportation planning [12]. An in-depth study differentiating the age of older people could be necessary to differentiate their needs.
Until 15 min. (%)
16 to 30 min. (%)
More than 31 min. (%)
Total (%)
Soft modes
87.0
13.0
0.0
100
Individual transport
73.9
19.6
6.5
100
Public transport
21.1
68.4
10.5
100
Various modes
61.5
23.1
15.4
100
Total
65.4
27.7
6.9
100
Table 3.
Time spent vs. transport mode to primary healthcare services by older people in LMA.
Different dynamics are observed in the demand for primary healthcare service by LMA’s ring, with a greater similarity between Lisbon & Ring 1 and Ring 4 compared with what is observed in Ring 2 and Ring 3 (Figure 6). In Lisbon & Ring 1 and Ring 4, there is a predominance of short-term trips/up to 15 minutes and a geographical proximity between the individuals and the destination (mainly in the parish of residence), and in the case of Lisbon & Ring 1 to the residence municipality. It is evident that geographical proximity is not particularly conducive to travel by soft/active modes, since it predominates the car use and public transport in the central area. This situation may result from several factors, namely the physical condition of the older person, the conditions of family support or related with perceptions about themselves and about the surrounding environment [4, 7, 15]. As a note, within this older people’s sample, 32% feel healthy, while 38% do not feel healthy (at different levels, but not discussed in depth in this work). About 48% of the older individuals do not feel safe to walk or cycle in the residence area (against 25% who assume the opposite), 41% consider that there is a lot of traffic, and 53% consider that there are high levels of noise and air pollution in the residence area.
Figure 6.
Synthesis of accessibility patterns to primary healthcare services by older people by LMA ring.
In turn, a greater diversity in the travel tie can be found in Ring 2 and Ring 3, with considerable proportion of respondents who spend more than 30 minutes looking for primary healthcare services. This situation is associated with the destinations of the trip, given the diversity of relevant destinations (parish, municipality, and other municipalities). Private transport maintains its predominance, complemented by the use of public transport in Ring 2 and by soft modes in Ring 3.
In this way, focusing on the RQ2, the expectation for an age-friendly environment related to walking accessibility to primary health services [4, 15, 18, 19, 20, 21, 22, 26] is not fully observed in the behavior of the surveyed population, that is, not everyone seeks to access the services under study on foot and in a short time. This situation is due to the combination of several factors, namely the organization of the health system itself (as some equipment is shared between communities and/or municipalities); to personal motivations and perceptions (e.g., insecurity feelings in public space); the physical and mental conditions and level of autonomy of individuals; or the use of complementary services provided by private or other entities (e.g., social institutions or local authorities). The differences between rings arise the importance to relate the results with context indicators of the urban environment in order to identify the main influencing factors of the emerged results [29].
5. Promoting equity minimizing older’s constraints to health accessibility in LMA
As it is not efficient to multiply the number of health services and associated physical and human resources in order to increase proximity to all users, it is essential to create complementary responses, prioritizing the most vulnerable users, and attracting several community stakeholders to the action [21, 22, 23, 45]. This will minimize risk situations caused by the retraction in the demand for health services and promote a better health for all.
The constraints to health accessibility by the olders are not a recent concern in the policy orientations of WHO for Age-friendly Cities [4]. Considering the proposed checklist for cities in the report “Global Age-friendly Cities: A Guide,” some premises in the domains of health services and transportation should be implemented. SHAFE project synthetized similar orientations, highlighting as well the main policy documents and possible stakeholders at several levels, to promote smart healthy age-friendly environments [21, 22].
Based on Table 4, it is highlighted the need of a health system with a varied offer of services, well distributed territorially and that answers to the community’s needs in the domain of health services. Complementarily, the existence of community support services is proposed, namely home services, which alleviates the strain on the service network and promotes better levels of health and well-being for the beneficiaries. On the other hand, and to promote a high quality transportation and a better accessibility level to health services, it is proposed the existence of a good public transport system in terms of affordability, frequency, quality, and comfort of vehicles, territorially spread and that responds to the major origin-destination needs. Quality of transport stops and stations is referred as well as they could be the first barrier to use public transports. As well, community transports are highly pointed to be complementary to the regular public transport system.
Domain age-friendly community and health services
Service accessibility
Planned distribution of health services and community services in the community/city in complementarity with the transport network;
Offer of services
Existence of an adequate diversity of services to the community and health services to promote health and minimize the disease;
Availability of home support services in the area of health and personal care suited to the needs of the community;
Domain age-friendly transportation
Affordability to all older people
Public transportation affordable to all older people, independently of their income level;
Reliability and frequency
Public transport reliable and frequent, including at night and at weekends periods;
Travel destinations
Existence of public transport routes to access to main destinations (e.g., health facilities, green spaces, commercial areas, etc.) within and between communities/cities;
Age-friendly vehicles / Priority seating
Infrastructural adaptation of vehicles suited to the physical capabilities of the older people (e.g., accesses, seats, priority spaces);
Transport stops and stations
Location of stops and stations suitable for the settlement system, especially considering the older people, with good safety, cleanliness, and easy access conditions;
Community transport
Existence of community transport services as a complement to public transport services, resorting to voluntary work and adapted vehicles.
Table 4.
Checklist for Age-friendly Cities in the domains of Community Services, Health Services, and Transportation. Source: own elaboration based on [4].
In the Portuguese case, municipalities and local organizations that have more proximity to the needs of each community have limited intervention to define policies and get funding to the healthcare model. While the local government involvement in the health domain is residual, other entities as social institutions and nongovernmental organizations present a high degree of organization and power, complementing the public health service [22]. This proves that external stakeholders to the Ministry of Health with health, social and transportation competences (e.g., local authorities, nongovernmental organizations, private institutions of social solidarity, transport operators) are more and more aware of their complementary role in supporting the proximity health service network and especially the older people as a vulnerable group with specific needs [21, 22, 23, 45]. In this sense, the provision of community support services has proved to be an asset as a way of bringing services that promote health and well-being closer to them.
In the Portuguese case, some actions are already in operation, namely tele-consultation, transport adapted to citizens, home deliveries of pharmaceutical or food products, home support, or even the adaptation of housing infrastructure (first factor of accessibility limitation) [22]. Specifically to LMA, some examples of recent strategies and/or actions that already exist in the municipalities of the LMA considered as good practices that complement the primary healthcare service formal structure should be highlighted.
5.1 Strategic plans oriented toward an healthy and inclusive aging
Assuming that aging is everyone’s business and that the community is the central place for aging policies, this issue begins to be evident in the design of strategic plans and measures that promote a more active, healthy, and sustainable aging process. Measures that promote better and easier accessibility of the older people to health services, applying not only the adaptation of infrastructures, but partnerships with local transport operators or the creation of innovative and informal responses are already a reality.
One of the examples is the Strategic Plan for Sustainable Aging 2016–2025 (PEES) of the municipal council of Amadora, which promotes a set of measures in favor of access and accessibility to health by the older [46]. As part of strategic objective 1 – Promoting safety and physical, psychological, social, and economic integrity of the older people, measures such as “Ensuring increased accessibility to health care for people aged 65+ classified with functional limitation/disability” or “Ensure increased accessibility to healthcare for people aged 65+ enrolled in ACES” stand out. In strategic objective 4 – Promoting mobility, transport and accessibility with better personal comfort and safety condition, we underlined measures such as: “Identify by 2023 public services without accessibility for people with reduced mobility”; “Put into operation in 6 parishes a door-to-door transport service for citizens with reduced mobility to travel to public services, health centers and hospitals”; and “Raise public transport operators’ awareness of the need to create or improve internal circuits in the county by 2025”.
5.2 Home-based healthcare or in the proximities
There are several solutions that have brought health services closer to their users. For example, several health services are carried out through the displacement of health teams or in which the need for physical displacement is replaced by telehealth services using several technologies (internet, telephone). Delegation of health services competences to other health service providers or partners in the health network (e.g., vaccination in pharmacies; medical care in municipal facilities or institutions of social support; home medication delivery) is already a reality in Portugal. Lastly, local autarchies or institutions of social support also provide health services.
In the period of the Covid-19 pandemic, since 2020, the Lisbon municipal council, in partnership with the Ministry of Health, has promoted an annual flu vaccination strategy benefiting around 165,000 olderly people [47]. This initiative is carried out recurring to mobile health units that travel to the neighborhoods (and, in case of need, to home), and counts on with the collaboration of other municipal entities, such as the parish councils and the fire brigades. The objective is to promote vaccination as a proximity service, preventing people from having to travel to health centers or other health facilities.
Articulated with ACES Oeiras and Lisboa Ocidental, since 2018, the municipal council of Oeiras makes available a home medical service—“Doctor at Home” for people over 65 years old who are beneficiaries of the Special Scheme for Participation in Medicines, identified according to the average income of households (currently meets the need of 2316 citizens) [48]. This service includes a specialized assistance service for triage, medical assistance available 24 hours a day by telephone, and medical consultations at home.
5.3 Promotion of flexible transport to reach health services
It is not only health services that are becoming increasingly flexible, but also transport responses have seen adapted to needs, especially to serve the most vulnerable populations and/or territories. In this way, the different levels of accessibility to health services are no longer such an evident exclusion criterion for the vulnerable fringes of the population. Improvements on the transport system responding to the older’s needs in terms of origin-destination, service schedules, adaptation of transport conditions (e.g., lowered entrances, space for wheelchair) are more and more considered, as the existence of flexible transport solutions (door-to-door transport, transport on demand), provided by local authorities, social entities, and transport operators.
In several LMA municipalities, stands out the “Solidarity Transport for the Olderly” initiative as a way to overcome the difficulties that the older people face in transport, minimizing situations of isolation, loneliness, and insecurity [49]. One of the areas where the project is being carried out is in the parish of Carnide, municipality of Lisbon, where the Parish Council has allied with the Association of Retired, Pensioners and Olders of Carnide to create a service for residents over 55 years of age. The destinations are not exclusive to health facilities, but also include commercial areas, green spaces, or any other destination (free of charge within the parish, scheduled by telephone).
In the municipality of Almada exists the inclusive mobility service “Almada BUS Saúde”. Operating since 2017, it has reached 500,000 users in early 2020, demonstrating its great utility [50]. With a circular route and without fixed stops, it aims to travel around the main health facilities in the city of Almada (hospital and health centers) and other public services. Beyond that, the vehicles are specially adapted to transport olderly people and people with reduced mobility.
Lastly, we highlight an equity measure implemented since April 2022 by the TML – Transportes Metropolitanos de Lisboa (Lisbon Metropolitan Transports), as the metropolitan transport authority. The TML decided to create a monthly metropolitan public transport pass with equal cost for all individuals (40 euros), independently of their origin destinations or the transportation modes, with particular adding benefits for specific groups as olders and students, giving a discount of 50% of the monthly cost to these groups [51].
Responding to RQ3, with this small set of examples (among many others already systematized), it is possible to observe the existence of a great diversity of solutions that promote equity in access to PHS in the LMA. The vast majority of the solutions observed are dynamized at the local/community level by different stakeholders. The solutions identified are at the level of policy instruments that frame the studied challenge, but also in the areas of health services and transport. This verification is in line with the theory principles promoting an age-friendly, healthy, inclusive, and sustainable environment considering multisectoral and multilevel approaches and calling on the various community stakeholders to actively participate in the solutions for more equitable communities and metropolises.
6. Final conclusions
This chapter discussed the walking accessibility to primary healthcare by the olders in Lisbon Metropolitan Area (LMA), Portugal, and its contribution for age-friendly environments as a factor of inequity, based on three research questions to which an answer is now given.
Since the health and transport networks are directly related to the LMA’s radioconcentric urbanization pattern, metropolitan rings also differentiate the levels of walking accessibility to primary health services. The management of services is essentially anchored in the criterion of the population served by equipment (as a way of maintaining its efficiency in terms of human and financial resources). Thus, denser areas register a network of health facilities with a greater number of equipment and proximity to each other (improving the walking accessibility level), while less dense areas and more dispersed occupation generate greater service catchment area, and hence greater distance between the user and the equipment by part of the population, affecting distance and distance–time measures. Hence, this relation between the health, settlement, and transport networks generates differentiated accessibility levels to healthcare, creating a situation of inequity within the metropolis.
As expected for age-friendly territories, generally, the demand for primary health services takes place through short-term travel. However, such distance time is partially solved through individual motorized modes, in contrast to the proposed modes (walking and public transport). This phenomenon may result from the combination of several factors that require in-depth study (inexistence of public transport? fear of walking? the service is too far? resorting to the family for travel?). Here, there were also different behaviors between the metropolitan rings, highlighting the influence of the characteristics of the health and transport networks in the individuals choices.
Finally, consistently with the guidelines of UN and WHO for age-friendly environments, it is possible to see in LMA the existence of some strategies, from local to metropolitan level, which complement the limitations of primary health services access by older. Such guidelines are evident (i) in strategic plans (in a top-down orientation); (ii) in the provision of health services at home or in areas closer to users promoted by local authorities, social partners, or other health service providers; and (iii) in flexible, affordable, and adapted transport strategies (both in a bottom-up orientation). These types of initiatives are minimizing inequity situations within and among the LMA’s communities.
The usefulness of this work is centered on three aspects: (1) effectiveness of the relationship between the theory relating to the construction of age-friendly environments and a methodology for evaluating situations of inequity in the metropolitan context centered on the principle of accessibility to primary health services; (2) possibility of methodological replication over time for this case study and/or for other territories and services; and (3) production of knowledge to support policy decision in the area of urban planning, and in particular in the fields of health and transportation, with utility at local, municipal, and metropolitan/regional levels, promoting a multisectoral and multilevel approaches. However, some limitations should be acknowledge, as the results are very dependent on the quality and timeliness of the data. For example, in this case, demographic data on the statistical subsection (the Portuguese smallest territorial unit possible) date from 2011, due to the unavailability of data from the 2021 Census until now. This generates possible discrepancies between what was elaborated and the reality, especially in areas of intense new urbanization or areas that are facing population losses. The same applies to the high variability of the organization of health services, with constant restructuring in terms of the equipment physical location and provided services, which can also generate outdated readings. Finally, in order to bring the analysis even closer to reality, the service areas in terms of served parishes of each equipment defined by law should be taken into account, implying an equipment-to-equipment methodological replication.
Hence, the multisectoral reading relating health services and transportation; the combination between the potential accessibility levels to primary health services based on modeling (representing the network supply) and the real behaviors of the older people (as the demand); and the identification of complementary solutions allow us to discuss the accessibility level to primary health services in a more complemented approach. This will better support the urban planning strategies and instruments toward more age-friendly, healthy, and inclusive environments; to a more competitive, social and territorial cohesive territories, and lastly, to more equitable communities and metropolitan areas.
Acknowledgments
This article was financed by national funds through FCT–Portuguese Foundation for Science and Technology, I.P., under the framework of the Project GRAMPCITY – Moving smartly toward accessible and inclusive urban environments for our elders (PTDC/GES-TRA/32121/2017), of the Master Scholarship “For more age-friendly mobility and accessibility in urban areas” (PTDC/GES-TRA/32121/2017-BI-LIC); of the PhD Scholarship “Planning the urban environment for healthy aging” (UI/BD/152227/2021), and the Research Unit (UIDB/00295/2020 and UIDP/00295/2020).
Walking speed of 3.5 km/h – Inhabitants with 65 or more years old
Until 15 min.
Until 30 min.
Until 60 min.
Total
Inhab. (N°)
Surface (Km2)
Inhab. (N°)
Surface (Km2)
Inhab. (N°)
Surface (Km2)
Inhab. (N°)
Surface (Km2)
Lisbon & Ring 1
147,936
54.69
212,279
135.6
215,703
155.54
215,810
175.11
Ring 2
74,885
44.78
113,889
123.08
135,835
276.44
139,209
381.13
Ring 3
37,734
34.74
67,197
114.23
81,395
306.42
87,496
705.61
Ring 4
31,277
38.59
49,328
117.79
61,781
389.13
71,327
1740.05
Total
291,832
172.8
442,693
490.7
494,714
1127.53
513,842
3001.9
Walking speed of 1.6 km/h—Inhabitants with 65 or more years old
Until 15 min.
Until 30 min.
Until 60 min.
Total
Inhab. (N°)
Surface (Km2)
Inhab. (N°)
Surface (Km2)
Inhab. (N°)
Surface (Km2)
Inhab. (N°)
Surface (Km2)
Lisbon & Ring 1
71,175
17
137,594
48.34
209,152
127.51
215,810
175.11
Ring 2
31,646
12.55
68,550
39.09
109,970
108.91
139,209
381.13
Ring 3
15,583
9.37
33,761
29.5
63,996
98.47
87,496
705.61
Ring 4
16,386
11.1
29,760
33.34
46,717
101.54
71,327
1740.05
Total
134,790
50.02
269,665
150.27
429,835
436.43
513,842
3001.9
\n',keywords:"older people, walking accessibility, primary health services, service catchment area, inequity, healthy cities, age-friendly environment, Lisbon Metropolitan Area",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/82903.pdf",chapterXML:"https://mts.intechopen.com/source/xml/82903.xml",downloadPdfUrl:"/chapter/pdf-download/82903",previewPdfUrl:"/chapter/pdf-preview/82903",totalDownloads:4,totalViews:0,totalCrossrefCites:0,dateSubmitted:"June 14th 2022",dateReviewed:"July 4th 2022",datePrePublished:"August 1st 2022",datePublished:null,dateFinished:"August 1st 2022",readingETA:"0",abstract:"This chapter discusses the walking accessibility to primary healthcare by the olders in Lisbon Metropolitan Area (LMA), Portugal, and its contribution for age-friendly environments as a factor of inequity. Constrains emerged from the collation of the supply approach, represented by service catchment areas based on walking distance time, and the demand approach, through a survey. The location and density of primary health network are a major factor, as it is related to distinct land use patterns within the LMA. The settlement structure influences the potential walkability to primary healthcare. The discrepancy between the potential walking accessibility and the real options is notorious, as olders` choices are diversified in terms of transportation modes and destinations, but mostly keeping relatively short time distances. This phenomenon is also influenced by factors such as personal preference, difficulty to walk, negative perceptions about the surroundings, and insufficient care support. This debate is already an effective concern of local authorities with spatial planning, social and health competences, insofar as solutions in terms of service flexibility and new travel solutions adapted to the specific needs of the olders are a growing reality in the LMA, promoting more age-friendly, health, and inclusive environments, and hence an equitable metropolis.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/82903",risUrl:"/chapter/ris/82903",signatures:"Eduarda Marques da Costa, Ana Louro, Nuno Marques da Costa, Mariana Dias and Marcela Barata",book:{id:"11479",type:"book",title:"Social Aspects of Ageing - Selected Challenges, Analyses, and Solutions",subtitle:null,fullTitle:"Social Aspects of Ageing - Selected Challenges, Analyses, and Solutions",slug:null,publishedDate:null,bookSignature:"Ph.D. Andrzej Klimczuk",coverURL:"https://cdn.intechopen.com/books/images_new/11479.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-80356-507-1",printIsbn:"978-1-80356-506-4",pdfIsbn:"978-1-80356-508-8",isAvailableForWebshopOrdering:!0,editors:[{id:"320017",title:"Ph.D.",name:"Andrzej",middleName:null,surname:"Klimczuk",slug:"andrzej-klimczuk",fullName:"Andrzej Klimczuk"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Accessibility to healthcare services for age-friendly environments",level:"1"},{id:"sec_3",title:"3. Methodological steps and case study framework",level:"1"},{id:"sec_4",title:"4. Supply and demand of primary healthcare services of LMA’s older people",level:"1"},{id:"sec_4_2",title:"4.1 Supply approach to primary healthcare system in LMA",level:"2"},{id:"sec_5_2",title:"4.2 The demand for primary healthcare services in the perspective of older people in LMA",level:"2"},{id:"sec_7",title:"5. Promoting equity minimizing older’s constraints to health accessibility in LMA",level:"1"},{id:"sec_7_2",title:"5.1 Strategic plans oriented toward an healthy and inclusive aging",level:"2"},{id:"sec_8_2",title:"5.2 Home-based healthcare or in the proximities",level:"2"},{id:"sec_9_2",title:"5.3 Promotion of flexible transport to reach health services",level:"2"},{id:"sec_11",title:"6. 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Available from: https://www.dgterritorio.gov.pt/Carta-de-Uso-e-Ocupacao-do-Solo-para-2018. [Accessed: May 07, 2022]'},{id:"B42",body:'Diário da República n. 38/2008, Série I de 2008-02-22 – Estabelece o regime da criação, estruturação e funcionamento dos agrupamentos de centros de saúde do Serviço Nacional de Saúde [Internet]. 2008. Available from: https://dre.pt/dre/detalhe/decreto-lei/28-2008-247675. [Accessed: May 26, 2022]'},{id:"B43",body:'Cuidados de Saúde Primários [Internet]. 2022. Available from: https://www.arslvt.min-saude.pt/pages/6247675. [Accessed: May 06, 2022]'},{id:"B44",body:'Beard JR, Petitot C. Ageing and urbanization: Can cities be designed to Foster active ageing? Public Health Reviews. 2010;32:427-450'},{id:"B45",body:'Louro A, Marques da Costa N, Marques da Costa E. A Cidade Saudável no planeamento municipal: exemplos de atuação na AML, Portugal. In: Soares BR, Marques da Costa N, Lima SC, Marques da Costa E, editors. Construindo cidades saudáveis: utopias e práticas. Uberlândia: Assis Editora; 2017. pp. 35-66'},{id:"B46",body:'Câmara Municipal da Amadora. VIVER BEM A IDADE – Plano Estratégico para o Envelhecimento Sustentável da Amadora 2016-2025. Amadora: CMA; 2021. p. 11'},{id:"B47",body:'Idosos vacinados contra a gripe em Lisboa sem terem de se deslocar ao centro de saúde [Internet]. 2020. Available from: https://dignus.pt/2020/09/23/idosos-vacinados-contra-a-gripe-em-lisboa-sem-terem-de-se-deslocar-ao-centro-de-saude/. [Accessed: May 19, 2022]'},{id:"B48",body:'Cinco apoios sociais para quem vive em Oeiras [Internet]. 2020. Available from: https://www.oeirasvalley.com/cinco-apoios-sociais-para-quem-vive-em-oeiras/. [Accessed: May 19, 2022]'},{id:"B49",body:'Transporte solidário para idosos – Serviços da Junta [Internet]. 2021. Available from: https://www.jf-carnide.pt/para-a-populacao/servicos-da-junta/servicos/Transporte-solidario-para-idosos/291/. [Accessed: May 19, 2022]'},{id:"B50",body:'Serviço de mobilidade inclusiva “Almada BUS Saúde” atinge os 500 mil utilizadores [Internet]. 1999. Available from: https://www.ageneal.pt/noticia/servico-de-mobilidade-inclusiva-almada-bus-saude-atinge-os-500-mil-utilizadores. [Accessed: May 19, 2022]'},{id:"B51",body:'Portal Viva. Passes Navegante [Internet]. 2022. Available from: https://www.portalviva.pt/pt/homepage/t%C3%ADtulos-de-transporte/uso-frequente/passes-navegante.aspx. [Accessed: May 01, 2022]'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Eduarda Marques da Costa",address:null,affiliation:'
Centre for Geographical Studies, Institute of Geography and Spatial Planning, University of Lisbon, Lisbon, Portugal
Centre for Geographical Studies, Institute of Geography and Spatial Planning, University of Lisbon, Lisbon, Portugal
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Definition of Terms:
\n\n
Book - collection of Works distributed in a book format, whose selection, coordination, preparation, and arrangement has been performed and published by IntechOpen, and in which the Work is included in its entirety in an unmodified form along with one or more other contributions, each constituting separate and independent sections, but together assembled into a collective whole.
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Work - a book Chapter (as well as Conference Papers), including any and all content, graphics, images and/or other materials forming part of, or accompanying, the Chapter/Conference Paper.
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Attribution – appropriate credit for the used Work or book.
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Creative Commons licenses – enable licensors to retain copyright while allowing others to use their Works in an appropriate way.
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Rules of Attribution for Works Published by IntechOpen
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With the purpose of protecting Authors' copyright and the transparent reuse of OA (Open Access) content, IntechOpen has developed Rules of Attribution of Works licensed under Creative Commons licenses.
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All Chapters published in IntechOpen books prior to October 2011 are licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported license (CC BY-NC-SA 3.0);
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All Chapters published in IntechOpen books after October 2011 are licensed under the Creative Commons Attribution 3.0 Unported license (CC BY 3.0);
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In case you reuse or republish any of the Works licensed under CC licenses, you must abide by the guidelines outlined below:
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1. Rules for reusing of books in their entirety or significant parts of books
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All rights to Books and other compilations published on the IntechOpen platform and in print are reserved by IntechOpen. The Copyright to Books and other compilations is subject to a separate Copyright from any that exists in the included Works.
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A Book in its entirety or a significant part of a Book cannot be translated freely without specific written consent by the publisher. Further information can be obtained at permissions@intechopen.com.
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In instances where permission is obtained from the publisher for reusing or republishing the Book, or significant parts of the Book, all of the following conditions apply:
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Information about the first publisher must be provided – please note the fact that the material was originally published by IntechOpen as an OA (Open Access) publication must be acknowledged;
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All original Academic Editor(s) must be credited;
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Since you are reusing content that someone else created and allowed you to use freely, you must credit all Authors involved;
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The type of license that is available for the Works must be indicated, as well as a link to the license provided, so that others can investigate the terms of the license. You will be aware that the material can be used for free in consequence of the CC license attribution, so you must acknowledge that fact. It is not sufficient that the material is Creative Commons, because that says nothing about how the material can actually be used. There are different CC licenses and you have to identify the specific license that is being used;
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Any original Copyright Notices associated, with the Works which constitute the Book must be kept intact;
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Provision of the original title of the Book, as well as the original titles of any individual Works;
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Provision of the URL where the Book is hosted, with a notice to the effect that the Book is an OA (Open Access) publication;
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Provision of the URL to every individual Work which constitutes the Book with a notice that the Work is an OA (Open Access) publication. As the material has been accessed for free, it is incumbent upon you to provide the source so that others can also access it for free.
\\n
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Every single Work that is used has to be attributed in the way described. If you are unsure about proper attribution, please write to permissions@intechopen.com.
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2. Rules of attribution for works published by IntechOpen
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Individual Works originally published in IntechOpen books are licensed under Creative Commons licenses and can be freely used under terms of the respective CC license, if properly attributed. In order to properly attribute the Work you must respect all the conditions outlined below:
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Credit all Authors – since you are reusing contents that someone created and allowed you to use freely, you have to acknowledge authorship;
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Indicate the type of license under which the Work is available and provide the URL to the license so others can find out the license terms. Preferably keep intact any original Copyright Notice associated with the Chapter (if any). You will be aware that the material can be used for free in consequence of the CC license attribution, so you must acknowledge that fact. It is not sufficient that the material is Creative Commons, because that says nothing about how the material can actually be used. There are different CC licenses and you have to identify the specific license that is being used;
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Provide the URL where the Work is hosted, preferably providing the original title of the Work, as well as the original title of the Book with a notification that the Work is an OA (Open Access) publication. As the material has been accessed for free, it is incumbent upon you to provide the source so that others can also access it for free;
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Provide information about the first publisher – please note the fact that the material was originally published by IntechOpen as an OA (Open Access) Work must be acknowledged.
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Every single Work that is used has to be attributed in the way as described. If you are unsure about proper attribution, please contact Us at permissions@intechopen.com.
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In the event that you use more than one of IntechOpen's Works published in one or more books (but not a significant part of the book that is under separate Copyright), each of these have to be properly attributed in the way described.
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IntechOpen does not have any claims on newly created copyrighted Works, but the Works originally published by IntechOpen must be properly attributed.
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All these rules apply to BOTH online and offline use.
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Parts of the Rules of Attribution are based on Work Attributing Creative Commons Materials published by the Australian Research Council Centre of Excellence for Creative Industries and Innovation, in partnership with Creative Commons Australia, which can be found at creativecommons.org.au licensed under Creative Commons Attribution 2.5 Australia license, and Best practices for attribution published by Creative Commons, which can be found at wiki.creativecommons.org under the Creative Commons Attribution 4.0 license.
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All the above rules are subject to change, IntechOpen reserves the right to take appropriate action if any of the conditions outlined above are not met.
Work - a book Chapter (as well as Conference Papers), including any and all content, graphics, images and/or other materials forming part of, or accompanying, the Chapter/Conference Paper.
\n\n
Attribution – appropriate credit for the used Work or book.
\n\n
Creative Commons licenses – enable licensors to retain copyright while allowing others to use their Works in an appropriate way.
\n\n
Rules of Attribution for Works Published by IntechOpen
\n\n
With the purpose of protecting Authors' copyright and the transparent reuse of OA (Open Access) content, IntechOpen has developed Rules of Attribution of Works licensed under Creative Commons licenses.
\n\n
\n\t
All Chapters published in IntechOpen books prior to October 2011 are licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported license (CC BY-NC-SA 3.0);
\n\t
All Chapters published in IntechOpen books after October 2011 are licensed under the Creative Commons Attribution 3.0 Unported license (CC BY 3.0);
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\n\n
In case you reuse or republish any of the Works licensed under CC licenses, you must abide by the guidelines outlined below:
\n\n
1. Rules for reusing of books in their entirety or significant parts of books
\n\n
All rights to Books and other compilations published on the IntechOpen platform and in print are reserved by IntechOpen. The Copyright to Books and other compilations is subject to a separate Copyright from any that exists in the included Works.
\n\n
A Book in its entirety or a significant part of a Book cannot be translated freely without specific written consent by the publisher. Further information can be obtained at permissions@intechopen.com.
\n\n
In instances where permission is obtained from the publisher for reusing or republishing the Book, or significant parts of the Book, all of the following conditions apply:
\n\n
\n\t
Information about the first publisher must be provided – please note the fact that the material was originally published by IntechOpen as an OA (Open Access) publication must be acknowledged;
\n\t
All original Academic Editor(s) must be credited;
\n\t
Since you are reusing content that someone else created and allowed you to use freely, you must credit all Authors involved;
\n\t
The type of license that is available for the Works must be indicated, as well as a link to the license provided, so that others can investigate the terms of the license. You will be aware that the material can be used for free in consequence of the CC license attribution, so you must acknowledge that fact. It is not sufficient that the material is Creative Commons, because that says nothing about how the material can actually be used. There are different CC licenses and you have to identify the specific license that is being used;
\n\t
Any original Copyright Notices associated, with the Works which constitute the Book must be kept intact;
\n\t
Provision of the original title of the Book, as well as the original titles of any individual Works;
\n\t
Provision of the URL where the Book is hosted, with a notice to the effect that the Book is an OA (Open Access) publication;
\n\t
Provision of the URL to every individual Work which constitutes the Book with a notice that the Work is an OA (Open Access) publication. As the material has been accessed for free, it is incumbent upon you to provide the source so that others can also access it for free.
\n
\n\n
Every single Work that is used has to be attributed in the way described. If you are unsure about proper attribution, please write to permissions@intechopen.com.
\n\n
2. Rules of attribution for works published by IntechOpen
\n\n
Individual Works originally published in IntechOpen books are licensed under Creative Commons licenses and can be freely used under terms of the respective CC license, if properly attributed. In order to properly attribute the Work you must respect all the conditions outlined below:
\n\n
\n\t
Credit all Authors – since you are reusing contents that someone created and allowed you to use freely, you have to acknowledge authorship;
\n\t
Indicate the type of license under which the Work is available and provide the URL to the license so others can find out the license terms. Preferably keep intact any original Copyright Notice associated with the Chapter (if any). You will be aware that the material can be used for free in consequence of the CC license attribution, so you must acknowledge that fact. It is not sufficient that the material is Creative Commons, because that says nothing about how the material can actually be used. There are different CC licenses and you have to identify the specific license that is being used;
\n\t
Provide the URL where the Work is hosted, preferably providing the original title of the Work, as well as the original title of the Book with a notification that the Work is an OA (Open Access) publication. As the material has been accessed for free, it is incumbent upon you to provide the source so that others can also access it for free;
\n\t
Provide information about the first publisher – please note the fact that the material was originally published by IntechOpen as an OA (Open Access) Work must be acknowledged.
\n
\n\n
Every single Work that is used has to be attributed in the way as described. If you are unsure about proper attribution, please contact Us at permissions@intechopen.com.
\n\n
In the event that you use more than one of IntechOpen's Works published in one or more books (but not a significant part of the book that is under separate Copyright), each of these have to be properly attributed in the way described.
\n\n
IntechOpen does not have any claims on newly created copyrighted Works, but the Works originally published by IntechOpen must be properly attributed.
\n\n
All these rules apply to BOTH online and offline use.
\n\n
Parts of the Rules of Attribution are based on Work Attributing Creative Commons Materials published by the Australian Research Council Centre of Excellence for Creative Industries and Innovation, in partnership with Creative Commons Australia, which can be found at creativecommons.org.au licensed under Creative Commons Attribution 2.5 Australia license, and Best practices for attribution published by Creative Commons, which can be found at wiki.creativecommons.org under the Creative Commons Attribution 4.0 license.
\n\n
All the above rules are subject to change, IntechOpen reserves the right to take appropriate action if any of the conditions outlined above are not met.
\n\n
Policy last updated: 2016-06-09
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Among these disasters—earthquake is the most- scary and damaging. The effects of a disaster, whether natural or human induced, are often long lasting. The Gorkha earthquake of 25 April 2015 enormously affected human, socio-economic and other multiple sectors and left deep scars mainly in the economy, livelihood and infrastructure of the country. Besides the natural factors, the damages from disasters in Nepal are in increasing trend due to the human activities and inadequate proactive legislations. Fundamentally, the weak structures have been found as the major cause of damage in earthquakes. This underlines the need for strict compliance of building codes. Thus, proactive disaster management legislation focusing on disaster preparedness is necessary. This paper analyses and shows the critical gaps and responsible factors that would contribute towards seismic risk reduction to enable various stakeholders to enhance seismic safety in Nepal. 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As research case studies, large earthquake disasters in Japan and Iran were investigated and analyzed. Normal distribution was found to be a good estimate of the magnitude distribution for earthquakes, in both the countries. In Japan, there is almost a linear correlation between magnitude of earthquakes and number of dead people. However, such correlation is not present for Iran. This lack of correlation in Iran and existence of linear correlation in Japan highlights that the magnitude of earthquakes directly affects the number of fatalities and extent of destruction in Japan, while in Iran, there is an increased complexity with regard to the factors affecting earthquake consequences. A correlation is suggested between earthquake culture and learning from large earthquake disasters in both Japan and Iran. Learning from large earthquake disasters is impacted by a multitude of factors, but the rhythm of learning in Japan is much higher if compared with Iran. For both Japan and Iran, a reactive learning approach based on past earthquake disasters needs to be constantly backed up by a proactive approach and dynamic learning.",book:{id:"6564",slug:"earthquakes-forecast-prognosis-and-earthquake-resistant-construction",title:"Earthquakes",fullTitle:"Earthquakes - Forecast, Prognosis and Earthquake Resistant Construction"},signatures:"Michaela Ibrion and Nicola Paltrinieri",authors:[{id:"209369",title:"Ph.D.",name:"Michaela",middleName:null,surname:"Ibrion",slug:"michaela-ibrion",fullName:"Michaela Ibrion"},{id:"244752",title:"Dr.",name:"Nicola",middleName:null,surname:"Paltrinieri",slug:"nicola-paltrinieri",fullName:"Nicola Paltrinieri"}]},{id:"28219",doi:"10.5772/28044",title:"Recent Landslide Damming Events and Their Hazard Mitigation Strategies",slug:"recent-landslide-damming-events-and-their-hazard-mitigation-strategies",totalDownloads:2232,totalCrossrefCites:4,totalDimensionsCites:6,abstract:null,book:{id:"2049",slug:"advances-in-geotechnical-earthquake-engineering-soil-liquefaction-and-seismic-safety-of-dams-and-monuments",title:"Advances in Geotechnical Earthquake Engineering",fullTitle:"Advances in Geotechnical Earthquake Engineering - Soil Liquefaction and Seismic Safety of Dams and Monuments"},signatures:"Ahsan Sattar and Kazuo Konagai",authors:[{id:"72541",title:"MSc.",name:"Ahsan",middleName:null,surname:"Sattar",slug:"ahsan-sattar",fullName:"Ahsan Sattar"},{id:"121222",title:"Prof.",name:"Kazuo",middleName:null,surname:"Konagai",slug:"kazuo-konagai",fullName:"Kazuo Konagai"}]}],mostDownloadedChaptersLast30Days:[{id:"47538",title:"An Updated Seismic Source Model for Egypt",slug:"an-updated-seismic-source-model-for-egypt",totalDownloads:3414,totalCrossrefCites:11,totalDimensionsCites:21,abstract:null,book:{id:"4488",slug:"earthquake-engineering-from-engineering-seismology-to-optimal-seismic-design-of-engineering-structures",title:"Earthquake Engineering",fullTitle:"Earthquake Engineering - From Engineering Seismology to Optimal Seismic Design of Engineering Structures"},signatures:"R. 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García\nHernández",authors:[{id:"77194",title:"Dr.",name:"José",middleName:"A.",surname:"Peláez",slug:"jose-pelaez",fullName:"José Peláez"},{id:"171273",title:"Dr.",name:"Rashad",middleName:null,surname:"Sawires",slug:"rashad-sawires",fullName:"Rashad Sawires"},{id:"171274",title:"Dr.",name:"María Teresa",middleName:null,surname:"García Hernández",slug:"maria-teresa-garcia-hernandez",fullName:"María Teresa García Hernández"},{id:"171275",title:"Dr.",name:"Raafat El-Shafey",middleName:null,surname:"Fat-Helbary",slug:"raafat-el-shafey-fat-helbary",fullName:"Raafat El-Shafey Fat-Helbary"},{id:"171276",title:"Dr.",name:"Hamza Ahmed",middleName:null,surname:"Ibrahim",slug:"hamza-ahmed-ibrahim",fullName:"Hamza Ahmed Ibrahim"}]},{id:"47738",title:"Earthquakes and Dams",slug:"earthquakes-and-dams",totalDownloads:3261,totalCrossrefCites:2,totalDimensionsCites:2,abstract:null,book:{id:"4488",slug:"earthquake-engineering-from-engineering-seismology-to-optimal-seismic-design-of-engineering-structures",title:"Earthquake Engineering",fullTitle:"Earthquake Engineering - From Engineering Seismology to Optimal Seismic Design of Engineering Structures"},signatures:"Hasan Tosun",authors:[{id:"79083",title:"Dr.",name:"Hasan",middleName:null,surname:"Tosun",slug:"hasan-tosun",fullName:"Hasan Tosun"}]},{id:"47881",title:"Simplified Multi-Block Constitutive Model Predicting the Seismic Displacement of Saturated Sands along Slip Surfaces with Strain Softening",slug:"simplified-multi-block-constitutive-model-predicting-the-seismic-displacement-of-saturated-sands-alo",totalDownloads:1163,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"4488",slug:"earthquake-engineering-from-engineering-seismology-to-optimal-seismic-design-of-engineering-structures",title:"Earthquake Engineering",fullTitle:"Earthquake Engineering - From Engineering Seismology to Optimal Seismic Design of Engineering Structures"},signatures:"Constantine A. Stamatopoulos",authors:[{id:"171228",title:"Dr.",name:"Constantine",middleName:null,surname:"Stamatopoulos",slug:"constantine-stamatopoulos",fullName:"Constantine Stamatopoulos"}]},{id:"67102",title:"Impacts of the 2015 Gorkha Earthquake: Lessons Learnt from Nepal",slug:"impacts-of-the-2015-gorkha-earthquake-lessons-learnt-from-nepal",totalDownloads:2248,totalCrossrefCites:5,totalDimensionsCites:9,abstract:"Nepal is highly vulnerable to a number of disasters for example: earthquakes, floods, landslides, fires, epidemics, avalanches, windstorms, hailstorms, lightning, glacier lake outburst floods, droughts and dangerous weather events. Among these disasters—earthquake is the most- scary and damaging. The effects of a disaster, whether natural or human induced, are often long lasting. The Gorkha earthquake of 25 April 2015 enormously affected human, socio-economic and other multiple sectors and left deep scars mainly in the economy, livelihood and infrastructure of the country. Besides the natural factors, the damages from disasters in Nepal are in increasing trend due to the human activities and inadequate proactive legislations. Fundamentally, the weak structures have been found as the major cause of damage in earthquakes. This underlines the need for strict compliance of building codes. Thus, proactive disaster management legislation focusing on disaster preparedness is necessary. This paper analyses and shows the critical gaps and responsible factors that would contribute towards seismic risk reduction to enable various stakeholders to enhance seismic safety in Nepal. Additionally, this chapter aims to pinpoint the deficiencies in disaster management system in Nepal with reference to the devastating Gorkha earthquake and suggest appropriate policy and advanced technical measures for improvement.",book:{id:"7660",slug:"earthquakes-impact-community-vulnerability-and-resilience",title:"Earthquakes",fullTitle:"Earthquakes - Impact, Community Vulnerability and Resilience"},signatures:"Shiva Subedi and Meen Bahadur Poudyal Chhetri",authors:[{id:"285969",title:"Mr.",name:"Shiva",middleName:null,surname:"Subedi",slug:"shiva-subedi",fullName:"Shiva Subedi"},{id:"293220",title:"Dr.",name:"Meen",middleName:null,surname:"Paudyal Chhetri",slug:"meen-paudyal-chhetri",fullName:"Meen Paudyal Chhetri"}]},{id:"63029",title:"An Estimation of “Energy” Magnitude Associated with a Possible Lithosphere-Atmosphere-Ionosphere Electromagnetic Coupling Before the Wenchuan MS8.0 Earthquake",slug:"an-estimation-of-energy-magnitude-associated-with-a-possible-lithosphere-atmosphere-ionosphere-elect",totalDownloads:1161,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"A large scale of abnormities from ground-based electromagnetic parameters to ionospheric parameters has been recorded during the Wenchuan MS8.0 earthquake. All these results present different anomalous periods, but there seems one common climax leading to a lithosphere-atmosphere-ionosphere electromagnetic coupling (LAIEC) right on May 9, 3 days prior to the Wenchuan main shock. Based on the electron-hole theory, this chapter attempts to estimate the “energy source” magnitude driving this obvious coupling with the Wenchuan focus zone parameters considered. The simulation results show that the total surface charges fall in ~107–108 C, and the related upward electric field is ~108–109 V/m. These corresponding parameters are up to 109 C and 1010 V/m when the main rupture happens, and the order of the output current is up to 107 A. The electric field increasing in the interface between the Earth’s surface and the atmosphere, on one hand, can cause electromagnetic parameter abnormities of ground-based observation, with the range beyond 1000 km. On the other hand, it can accumulate air ionization above pre-earthquake zone and lead to ionospheric anomaly recorded by some spatial seismic monitoring satellites.",book:{id:"6564",slug:"earthquakes-forecast-prognosis-and-earthquake-resistant-construction",title:"Earthquakes",fullTitle:"Earthquakes - Forecast, Prognosis and Earthquake Resistant Construction"},signatures:"Mei Li, Wenxin Kong, Chong Yue, Shu Song, Chen Yu, Tao Xie and\nXian Lu",authors:[{id:"236284",title:"Dr.",name:"Mei",middleName:null,surname:"Li",slug:"mei-li",fullName:"Mei Li"},{id:"243785",title:"MSc.",name:"Chen",middleName:null,surname:"Yu",slug:"chen-yu",fullName:"Chen Yu"},{id:"243786",title:"MSc.",name:"Chong",middleName:null,surname:"Yue",slug:"chong-yue",fullName:"Chong Yue"},{id:"243788",title:"Dr.",name:"Tao",middleName:null,surname:"Xie",slug:"tao-xie",fullName:"Tao Xie"},{id:"243789",title:"MSc.",name:"Wenxin",middleName:null,surname:"Kong",slug:"wenxin-kong",fullName:"Wenxin Kong"},{id:"243790",title:"BSc.",name:"Shu",middleName:null,surname:"Song",slug:"shu-song",fullName:"Shu Song"}]}],onlineFirstChaptersFilter:{topicId:"778",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:108,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:330,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:9,numberOfPublishedChapters:140,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:123,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:22,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:11,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403",scope:"Artificial Intelligence (AI) is a rapidly developing multidisciplinary research area that aims to solve increasingly complex problems. In today's highly integrated world, AI promises to become a robust and powerful means for obtaining solutions to previously unsolvable problems. This Series is intended for researchers and students alike interested in this fascinating field and its many applications.",coverUrl:"https://cdn.intechopen.com/series/covers/14.jpg",latestPublicationDate:"July 5th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:9,editor:{id:"218714",title:"Prof.",name:"Andries",middleName:null,surname:"Engelbrecht",slug:"andries-engelbrecht",fullName:"Andries Engelbrecht",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRNR8QAO/Profile_Picture_1622640468300",biography:"Andries Engelbrecht received the Masters and PhD degrees in Computer Science from the University of Stellenbosch, South Africa, in 1994 and 1999 respectively. He is currently appointed as the Voigt Chair in Data Science in the Department of Industrial Engineering, with a joint appointment as Professor in the Computer Science Division, Stellenbosch University. Prior to his appointment at Stellenbosch University, he has been at the University of Pretoria, Department of Computer Science (1998-2018), where he was appointed as South Africa Research Chair in Artifical Intelligence (2007-2018), the head of the Department of Computer Science (2008-2017), and Director of the Institute for Big Data and Data Science (2017-2018). In addition to a number of research articles, he has written two books, Computational Intelligence: An Introduction and Fundamentals of Computational Swarm Intelligence.",institutionString:null,institution:{name:"Stellenbosch University",institutionURL:null,country:{name:"South Africa"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:6,paginationItems:[{id:"22",title:"Applied Intelligence",coverUrl:"https://cdn.intechopen.com/series_topics/covers/22.jpg",isOpenForSubmission:!0,annualVolume:11418,editor:{id:"27170",title:"Prof.",name:"Carlos",middleName:"M.",surname:"Travieso-Gonzalez",slug:"carlos-travieso-gonzalez",fullName:"Carlos Travieso-Gonzalez",profilePictureURL:"https://mts.intechopen.com/storage/users/27170/images/system/27170.jpeg",biography:"Carlos M. Travieso-González received his MSc degree in Telecommunication Engineering at Polytechnic University of Catalonia (UPC), Spain in 1997, and his Ph.D. degree in 2002 at the University of Las Palmas de Gran Canaria (ULPGC-Spain). He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. He won the “Catedra Telefonica” Awards in Modality of Knowledge Transfer, 2017, 2018, and 2019 editions, and awards in Modality of COVID Research in 2020.\n\nPublic References:\nResearcher ID http://www.researcherid.com/rid/N-5967-2014\nORCID https://orcid.org/0000-0002-4621-2768 \nScopus Author ID https://www.scopus.com/authid/detail.uri?authorId=6602376272\nScholar Google https://scholar.google.es/citations?user=G1ks9nIAAAAJ&hl=en \nResearchGate https://www.researchgate.net/profile/Carlos_Travieso",institutionString:null,institution:{name:"University of Las Palmas de Gran Canaria",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"23",title:"Computational Neuroscience",coverUrl:"https://cdn.intechopen.com/series_topics/covers/23.jpg",isOpenForSubmission:!0,annualVolume:11419,editor:{id:"14004",title:"Dr.",name:"Magnus",middleName:null,surname:"Johnsson",slug:"magnus-johnsson",fullName:"Magnus Johnsson",profilePictureURL:"https://mts.intechopen.com/storage/users/14004/images/system/14004.png",biography:"Dr Magnus Johnsson is a cross-disciplinary scientist, lecturer, scientific editor and AI/machine learning consultant from Sweden. \n\nHe is currently at Malmö University in Sweden, but also held positions at Lund University in Sweden and at Moscow Engineering Physics Institute. \nHe holds editorial positions at several international scientific journals and has served as a scientific editor for books and special journal issues. \nHis research interests are wide and include, but are not limited to, autonomous systems, computer modeling, artificial neural networks, artificial intelligence, cognitive neuroscience, cognitive robotics, cognitive architectures, cognitive aids and the philosophy of mind. \n\nDr. Johnsson has experience from working in the industry and he has a keen interest in the application of neural networks and artificial intelligence to fields like industry, finance, and medicine. \n\nWeb page: www.magnusjohnsson.se",institutionString:null,institution:{name:"Malmö University",institutionURL:null,country:{name:"Sweden"}}},editorTwo:null,editorThree:null},{id:"24",title:"Computer Vision",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",isOpenForSubmission:!0,annualVolume:11420,editor:{id:"294154",title:"Prof.",name:"George",middleName:null,surname:"Papakostas",slug:"george-papakostas",fullName:"George Papakostas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hYaGbQAK/Profile_Picture_1624519712088",biography:"George A. Papakostas has received a diploma in Electrical and Computer Engineering in 1999 and the M.Sc. and Ph.D. degrees in Electrical and Computer Engineering in 2002 and 2007, respectively, from the Democritus University of Thrace (DUTH), Greece. Dr. Papakostas serves as a Tenured Full Professor at the Department of Computer Science, International Hellenic University, Greece. Dr. Papakostas has 10 years of experience in large-scale systems design as a senior software engineer and technical manager, and 20 years of research experience in the field of Artificial Intelligence. Currently, he is the Head of the “Visual Computing” division of HUman-MAchines INteraction Laboratory (HUMAIN-Lab) and the Director of the MPhil program “Advanced Technologies in Informatics and Computers” hosted by the Department of Computer Science, International Hellenic University. He has (co)authored more than 150 publications in indexed journals, international conferences and book chapters, 1 book (in Greek), 3 edited books, and 5 journal special issues. His publications have more than 2100 citations with h-index 27 (GoogleScholar). His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null},{id:"25",title:"Evolutionary Computation",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",isOpenForSubmission:!0,annualVolume:11421,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. Dr Ventura also holds the positions of Affiliated Professor at Virginia Commonwealth University (Richmond, USA) and Distinguished Adjunct Professor at King Abdulaziz University (Jeddah, Saudi Arabia). Additionally, he is deputy director of the Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI) and heads the Knowledge Discovery and Intelligent Systems Research Laboratory. He has published more than ten books and over 300 articles in journals and scientific conferences. Currently, his work has received over 18,000 citations according to Google Scholar, including more than 2200 citations in 2020. In the last five years, he has published more than 60 papers in international journals indexed in the JCR (around 70% of them belonging to first quartile journals) and he has edited some Springer books “Supervised Descriptive Pattern Mining” (2018), “Multiple Instance Learning - Foundations and Algorithms” (2016), and “Pattern Mining with Evolutionary Algorithms” (2016). He has also been involved in more than 20 research projects supported by the Spanish and Andalusian governments and the European Union. He currently belongs to the editorial board of PeerJ Computer Science, Information Fusion and Engineering Applications of Artificial Intelligence journals, being also associate editor of Applied Computational Intelligence and Soft Computing and IEEE Transactions on Cybernetics. Finally, he is editor-in-chief of Progress in Artificial Intelligence. He is a Senior Member of the IEEE Computer, the IEEE Computational Intelligence, and the IEEE Systems, Man, and Cybernetics Societies, and the Association of Computing Machinery (ACM). Finally, his main research interests include data science, computational intelligence, and their applications.",institutionString:null,institution:{name:"University of Córdoba",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"26",title:"Machine Learning and Data Mining",coverUrl:"https://cdn.intechopen.com/series_topics/covers/26.jpg",isOpenForSubmission:!0,annualVolume:11422,editor:{id:"24555",title:"Dr.",name:"Marco Antonio",middleName:null,surname:"Aceves Fernandez",slug:"marco-antonio-aceves-fernandez",fullName:"Marco Antonio Aceves Fernandez",profilePictureURL:"https://mts.intechopen.com/storage/users/24555/images/system/24555.jpg",biography:"Dr. Marco Antonio Aceves Fernandez obtained his B.Sc. (Eng.) in Telematics from the Universidad de Colima, Mexico. He obtained both his M.Sc. and Ph.D. from the University of Liverpool, England, in the field of Intelligent Systems. He is a full professor at the Universidad Autonoma de Queretaro, Mexico, and a member of the National System of Researchers (SNI) since 2009. Dr. Aceves Fernandez has published more than 80 research papers as well as a number of book chapters and congress papers. He has contributed in more than 20 funded research projects, both academic and industrial, in the area of artificial intelligence, ranging from environmental, biomedical, automotive, aviation, consumer, and robotics to other applications. He is also a honorary president at the National Association of Embedded Systems (AMESE), a senior member of the IEEE, and a board member of many institutions. His research interests include intelligent and embedded systems.",institutionString:"Universidad Autonoma de Queretaro",institution:{name:"Autonomous University of Queretaro",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null},{id:"27",title:"Multi-Agent Systems",coverUrl:"https://cdn.intechopen.com/series_topics/covers/27.jpg",isOpenForSubmission:!0,annualVolume:11423,editor:{id:"148497",title:"Dr.",name:"Mehmet",middleName:"Emin",surname:"Aydin",slug:"mehmet-aydin",fullName:"Mehmet Aydin",profilePictureURL:"https://mts.intechopen.com/storage/users/148497/images/system/148497.jpg",biography:"Dr. Mehmet Emin Aydin is a Senior Lecturer with the Department of Computer Science and Creative Technology, the University of the West of England, Bristol, UK. His research interests include swarm intelligence, parallel and distributed metaheuristics, machine learning, intelligent agents and multi-agent systems, resource planning, scheduling and optimization, combinatorial optimization. Dr. Aydin is currently a Fellow of Higher Education Academy, UK, a member of EPSRC College, a senior member of IEEE and a senior member of ACM. In addition to being a member of advisory committees of many international conferences, he is an Editorial Board Member of various peer-reviewed international journals. He has served as guest editor for a number of special issues of peer-reviewed international journals.",institutionString:null,institution:{name:"University of the West of England",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:20,paginationItems:[{id:"83065",title:"Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children",doi:"10.5772/intechopen.106469",signatures:"Andrew Macnab",slug:"interventions-and-practical-approaches-to-reduce-the-burden-of-malaria-on-school-aged-children",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:[{name:"Andrew",surname:"Macnab"}],book:{title:"Malaria - Recent Advances, and New Perspectives",coverURL:"https://cdn.intechopen.com/books/images_new/11576.jpg",subseries:{id:"5",title:"Parasitic Infectious Diseases"}}},{id:"82804",title:"Psychiatric Problems in HIV Care",doi:"10.5772/intechopen.106077",signatures:"Seggane Musisi and Noeline Nakasujja",slug:"psychiatric-problems-in-hiv-care",totalDownloads:2,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Future Opportunities and Tools for Emerging Challenges for HIV/AIDS Control",coverURL:"https://cdn.intechopen.com/books/images_new/11575.jpg",subseries:{id:"6",title:"Viral Infectious Diseases"}}},{id:"82827",title:"Epidemiology and Control of Schistosomiasis",doi:"10.5772/intechopen.105170",signatures:"Célestin Kyambikwa Bisangamo",slug:"epidemiology-and-control-of-schistosomiasis",totalDownloads:6,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"New Horizons for Schistosomiasis Research",coverURL:"https://cdn.intechopen.com/books/images_new/10829.jpg",subseries:{id:"5",title:"Parasitic Infectious Diseases"}}},{id:"82817",title:"Perspective Chapter: Microfluidic Technologies for On-Site Detection and Quantification of Infectious Diseases - The Experience with SARS-CoV-2/COVID-19",doi:"10.5772/intechopen.105950",signatures:"Andres Escobar and Chang-qing Xu",slug:"perspective-chapter-microfluidic-technologies-for-on-site-detection-and-quantification-of-infectious",totalDownloads:3,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"SARS-CoV-2 Variants - Two Years After",coverURL:"https://cdn.intechopen.com/books/images_new/11573.jpg",subseries:{id:"6",title:"Viral Infectious Diseases"}}}]},overviewPagePublishedBooks:{paginationCount:13,paginationItems:[{type:"book",id:"6667",title:"Influenza",subtitle:"Therapeutics and Challenges",coverURL:"https://cdn.intechopen.com/books/images_new/6667.jpg",slug:"influenza-therapeutics-and-challenges",publishedDate:"September 19th 2018",editedByType:"Edited by",bookSignature:"Shailendra K. 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He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"117248",title:"Dr.",name:"Andrew",middleName:null,surname:"Macnab",slug:"andrew-macnab",fullName:"Andrew Macnab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of British Columbia",country:{name:"Canada"}}},{id:"322007",title:"Dr.",name:"Maria Elizbeth",middleName:null,surname:"Alvarez-Sánchez",slug:"maria-elizbeth-alvarez-sanchez",fullName:"Maria Elizbeth Alvarez-Sánchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",country:{name:"Mexico"}}},{id:"337443",title:"Dr.",name:"Juan",middleName:null,surname:"A. Gonzalez-Sanchez",slug:"juan-a.-gonzalez-sanchez",fullName:"Juan A. Gonzalez-Sanchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico System",country:{name:"United States of America"}}},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}}]}},subseries:{item:{id:"8",type:"subseries",title:"Bioinspired Technology and Biomechanics",keywords:"Bioinspired Systems, Biomechanics, Assistive Technology, Rehabilitation",scope:'Bioinspired technologies take advantage of understanding the actual biological system to provide solutions to problems in several areas. Recently, bioinspired systems have been successfully employing biomechanics to develop and improve assistive technology and rehabilitation devices. The research topic "Bioinspired Technology and Biomechanics" welcomes studies reporting recent advances in bioinspired technologies that contribute to individuals\' health, inclusion, and rehabilitation. Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11404,editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",slug:"adriano-andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",biography:"Dr. Adriano de Oliveira Andrade graduated in Electrical Engineering at the Federal University of Goiás (Brazil) in 1997. He received his MSc and PhD in Biomedical Engineering respectively from the Federal University of Uberlândia (UFU, Brazil) in 2000 and from the University of Reading (UK) in 2005. He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. 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Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",annualVolume:11405,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"35539",title:"Dr.",name:"Cecilia",middleName:null,surname:"Cristea",fullName:"Cecilia Cristea",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYQ65QAG/Profile_Picture_1621007741527",institutionString:null,institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"40735",title:"Dr.",name:"Gil",middleName:"Alberto Batista",surname:"Gonçalves",fullName:"Gil Gonçalves",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYRLGQA4/Profile_Picture_1628492612759",institutionString:null,institution:{name:"University of Aveiro",institutionURL:null,country:{name:"Portugal"}}},{id:"211725",title:"Associate Prof.",name:"Johann F.",middleName:null,surname:"Osma",fullName:"Johann F. 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