Safety driven regulatory actions from 2010 to 2015: a comparative study between EU and US

Tese de mestrado, Regulação e Avaliação do Medicamento e Produtos de Saúde, Universidade de Lisboa, Faculdade de Farmácia, 2018O incompleto perfil de segurança dos novos medicamentos e o insuficiente conhecimento da relação benefício-risco no momento uma autorização de introdução no mercado (AIM) é concedida são premisas estabelecidas em farmacovigilânica. Na verdade, elas mesmas justificam a contínua monitorização do perfil de segurança dos medicamentos com AIM aprovada e identificação de riscos associados à sua utilização – actividades essenciais à manutenção da própria AIM. Ora, a deteção e avaliação de reacções adversas aos medicamentos, seguida do estabelecimento de medidas de prevenção e minimização de risco, não só fazem parte da missão da farmacovigilância, como também integram os objectivos e responsabilidades das agências reguladoras e da indústria farmacêutica. Algumas publicações científicas procuraram, ao longo dos anos, versar sobre estas mesmas medidas de prevenção e minimização de risco, mediante o estudo do conjunto de acções regulamentares face a questões de segurança. Na sua maioria, a análise foi efectuada em contextos singulares, como o caso de produtos biológicos, medicamentos órfãos, medicamentos com AIM concedida em circunstâncias excecionais, ou considerando as acções regulamentares no contexto de um determinado país ou pequeno grupo de países, como é o caso de exemplos publicados no Reino Unido, Espanha, Estados Unidos da América e Holanda. Os resultados obtidos sugerem que tais acções regulamentares foram desencadeadas pelas autoridades reguladoras em cerca de 9 a 25% dos medicamentos com AIM aprovada em análise. Dois outros estudos denotam que, entre 1975 e 1999, pelo menos uma acção regulamentar foi tomada em função de problemas de segurança para 10% dos medicamentos com AIM aprovada nos Estados Unidos da América. Mais recentemente, um conjunto de productos biológicos foi associado a uma probabilidade de 14% de necessitar de uma primeira acção regulamentar derivada de questões de segurança nos primeiros 3 anos após a aprovação da AIM. Sendo que, para a mesma classe de medicamentos, os produtos biológicos com a primeira aprovação de AIM possuiam um risco acrescido de requerer tais acções de segurança. No entanto, e apesar das várias agências reguladoras dos medicamentos e productos de saúde possuírem, objectivos e responsabilidades semelhantes no que tangue à necessidade de garantir a qualidade, eficácia e segurança dos medicamentos nos mercados em que actuam, nem sempre partilham da mesma interpretação e tomada de decisão face a um determinado conjunto de informações de segurança e eficácia para um mesmo medicamento. As diferenças nos enquadramentos regulamentares, nas estruturas organizacionais e no modo de funcionamento das agências dos Estados Unidos da América (FDA) e da União Europeia (EMA) encontram-se descritas em detalhe na literatura publicada, tendo sido extensamente analizadas e comparadas. Ao longo das últimas decadas, estas desemelhanças têm conduzindo a avaliações e recommendações divergentes. No âmbito da aprovação de medicamentos e produtos de saúde, a literatura analisada denota que, entre 1995 e 2008, 20% dos medicamentos oncológicos em estudo possuiam uma AIM aprovada pela FDA ou pela EMA, mas não por ambas. De igual modo, o conteúdo do resumo das caracteristicas possuía importantes diferenças em 28% do conjunto de medicamentos com AIM aprovada nos dois territórios. Finalmente, existem vários exemplos de decisões distintas no que se refere a acções regulamentares derivadas de questões de segurança num contexto pós-AIM, alguns dos quais particulamente mediáticos, como é o caso da rosiglitazona. Por outro lado, importantes desenvolvimentos regulamentares tiveram lugar no contexto da farmacovigilância, quer no território dos Estados Unidos da América, em 2007, quer na União Europeia, em 2012. Estas alterações legislativas pretendiam, entre outros objectivos, dotar as referidas agências de mais recursos e de um maior poder de decisão, implementando, ao mesmo tempo, um conjunto mais rigoroso de requerimentos e obrigações para a indústria farmacêutica/para os detentores de AIM. Perante este cenário de alterações legislativas e na ausência de uma recente análise das acções regulamentares derivadas de questões de segurança para um conjunto mais abrangente de medicamentos, este estudo foi proposto. A elaboração desta tese possui como objectivo o estudo, análise e discussão das acções regulamentares derivadas de questões de segurança entre 2010 e 2015, nos Estados Unidos da América e na União Europeia. Paralelamente, propõe-se a considerar a frequência, o timing após a AIM ter sido concedida e a natureza destas mesmas acções regulamentares, bem como a analisar quais as áreas/classes terapêuticas com maior número de acções regulamentares derivadas de questões de segurança. As actividades regulamentares da EMA e da FDA, bem como as decisões em estudo, serão comparadas e analisadas, visando reflectir-se sobre a aparente reduzida harmonização na avaliação de medicamentos e produtos de saúde entre estas duas autoridades. Por fim, de modo a ilustrar as diferenças descritas, é apresentado um caso de estudo de um medicamento associado a uma recente discussão de segurança, e do conjunto de acções regulamentares tomadas em ambos os territórios. Um estudo/descrição abrangente da história, estrutura organizacional, processos e missão das autoridades reguladoras em questão foi efectuado. As diferenças substânciais entre a FDA e a EMA no que se refere às atividades de farmacovigilância e acções regulamentares em função de questões de segurança foram igualmente analisadas. Simultaneamente, procurou-se estabelecer pontos de convergência no que respeita às responsabilidades e objectivos propostos, e ilustrar as múltiplas iniciativas de importante colaboração entre as agências destas duas regiões. Para a análise das acções regulamentares foram consideradas (i) as comunicações dirigidas aos profissionais de saúde (Direct Heathcare Professional Communication - DHPC) publicadas em Portugal, no Reino Unido e as Dear Health Care Professional (DHCP) Letter nos Estados Unidos da América e (ii) as revogações de AIM em medicamentos comercializados na União Europeia em associação aos medicamentos retirados do mercado nos Estados Unidos da América por questões de segurança. Os resultados obtidos indicam um maior recurso às comunicações dirigidas aos profissionais de saúde nos países da União Europeia que nos Estados Unidos da América, no período entre 2010 e 2015. A disseminação dos riscos de segurança associados aos produtos comercializados nos Estados Unidos da América decorre, de acordo com dos dados disponíveis, através de outras ferramentas de informação comunicação de risco, actualmente disponíveis para a FDA. Dentro da globalidade dos dados analisadas, as pequenas moléculas apresentaram quer um maior número de comunicações de segurança, quer uma maior frequência de revogação/suspensão de AIM por razões de segurança. Por outro lado, os eventos adversos relacionados com os distúrbios cardíacos surgem como um dos principais impulsionadores das acções de segurança para as pequenas moléculas. Os dados obtidos demonstram ainda uma necessidade crescente de enfoque no que concerne a questões de segurança devido a erros de medicação. Resultados estes suportados pelas conclusões presentes na literatura actualmente publicada. De igual modo, as notificações espontâneas de reacções adversas a medicamentos continuam a representar a maior fonte de informação de segurança desencadeadora de de comunicações dirigidas aos profissionais de saúde como acção regulamentar em todos os países analisados. Todavia, verifica-se uma crescente utilização de dados de ensaios clínicos e estudos epidemiológicos tanto na identificação, como na avaliação de problemas de segurança, o que sugere um real incremento da importância dos mesmos no universo da farmacovigilância. Finalmente, no que diz respeito ao timing das acções regulamentares, 66,6% das revogações de AIM por questões de segurança tiveram lugar até 5 anos após a aprovação da AIM, enquanto que 50,4% das comunicações dirigidas aos profissionais de saúde foram emitidas até 6 anos após a aprovação da AIM. O caso de estudo escolhido versou sobre as recentes discussões de segurança relativamente ao ácido valpróico (e derivados) e sua utilização em crianças, mulheres de idade fértil e grávidas, nomeadamente face aos riscos de malformações congénitas, alterações estruturais graves e importantes efeitos neurológicos adversos nestas subpopulações. O contexto da utlização destes medicamentos foi descrito e as recomendações/acções regulamentares da FDA e EMA, bem como de algumas autoridades nacionais de estados membros da União Europeia, apresentadas. Os diferentes mecanismos e estruturas nos processos de farmacovigilância implementados e os instrumentos/medidas de minimização de risco disponíveis para cada uma das entidades reguladoras parecem justificar as diferentes recomendações e decisões observadas. Por outro lado, observam-se importantes dissemelhanças na estrutura e no conteúdo do resumo das características do medicaments/folheto informativo nestas duas regiões. Pela observação dos aspectos em estudo conclui-se que a análise e contextualização do quadro legislativo e do conjunto de processos e procedimentos actualmente disponíveis para a FDA e para a EMA é fundamentar no entendimento das decisões regulamentares e nas recomendações face a questões de segurança de medicamentos. A familiardidade com estes conceitos poderá promover uma maior sensibilização e entendimento, não só dos profissionais de saúde, mas também dos doentes e da população em geral, quer no que tange às avalições de medicamentos aquando do pedido de AIM, quer no que se refere às análise de dados de eficácia, qualidade ou segurança, que suportam a gestão de sinais, as alterações no conteúdo do resumo das característica do medicamento/folheto informativo, a implementação de medidas adicionais de minimização de risco e as decisões de revogação/suspensão de uma AIM. Verificou-se ainda que a natureza dinâmica dos processos regulamentares no âmbito da farmacovigilância permanece bastante atual, pelo que a necessidade de colaboração permanente entre os múltiplos intervenientes é fundamental na redução da duplicação de esforços e no suporte dos processos de avaliação, concessão e manutenção das AIM, em benefício dos reguladores, indústria farmacêutica e particularmente dos doentes.The natural history of approved drugs comprehends the discovery of new and important safety information in the post-marketing setting. In fact, studies show that for 9 to 25% of the drugs analysed, national or regional regulatory authorities required a safety-related regulatory action after their approval. Over the years, these publications have analysed safety-related regulatory actions, mostly on specific settings, such as for particular drug groups (e.g. biologicals, orphan medicines and exceptional circumstances/ conditional (accelerated) approval procedures) or individual countries. On the other hand, although current FDA and EMA guidance are driven by similar objectives regarding the identification, monitoring and minimization of risks, commonly leading to generation of similar data needs, there are cases where the two regulatory agencies have recommended distinct regulatory actions in response to the same safety issues identified. Substantial differences have also been identified with regards to risk communication and in monitoring implementation of risk minimization measures. Therefore, this study proposes to discuss and characterize the regulatory framework of pharmacovigilance activities within the European Union region and the United States of America, and analyse and compare the safety-driven regulatory actions for medicinal products, both small molecules and biologics, between the years of 2010 and 2015, following updates in applicable regulations in 2007 (for the US) and in 2012 (for the EU). The frequency, timing and nature of such regulatory actions evaluated, as well as the most impacted therapeutic groups. The direct communications to healthcare providers disseminated in Portugal, United Kingdom and US and the requests of withdrawal of medicinal products in the EU and the US territories were considered when analysing safety-related regulatory actions. Such recommendations provided by the EMA and the FDA were used to discuss the apparent lack of consistency in the assessment of medicinal products by these regulatory bodies. Finally, a case-study of a drug whose safety profile has been recently under evaluation in both territories is presented, and the recommendations/safety-related regulatory actions taken described. The results suggest that direct communications to healthcare providers are more frequently distributed in the EU than the US, with the majority of the safety risks associated to marketed products in the US territory having been announced to HCP and the general public by other risk communication tools currently available to the FDA. Both safety driven direct communications to healthcare providers and withdrawals were more frequent for small molecule medicinal products. Additionally, the data retrieved supports previous findings on differences having been shown to exist in the nature of the safetyrelated regulatory actions for biologicals compared with small molecules. Cardiac disorders related AE appear as a leading trigger for safety-driven regulatory actions for small molecules. Evidence also suggests more efforts still need to be allocated for tackling medication error-related adverse events. Spontaneous reports continue to account for the majority of the source data for triggering safety driven direct communications to healthcare providers in all regions, but relevant findings originating from clinical trials and epidemiological studies were observed, supporting the increasing importance of these sources in identifying and evaluating safety issues. With regards to timing of regulatory action, 66.6% of the safety-related withdrawals were issued within 5 years after approval, while 50.4% of the safety driven direct communications to healthcare providers were issued within 6 years after approval. The use of valproic acid in children, women of childbearing potential and during pregnancy given the associated risks of congenital malformations, major structural abnormalities and serious neurodevelopmental effects was chosen as case study. The distinct set of regulatory actions taken might be justified by the structurally different pharmacovigilance implemented mechanisms and instruments available to regulators in each territory but also given the inconsistencies in both structure and content of the labelling information between EU and US territories and to some extent within in EU territories. Given the study performed, it is possible to conclude that the analysis and contextualization of the on legislative framework and processes of the FDA and the EMA is essential to understand the agencies regulatory decisions and recommendations. Dissemination of these may help improve overall awareness and allow for a better insight and understanding on matters of divergent drug approvals and post-marketing safety recommendations, either it being signal management activities, label updates, additional risk minimization measures and withdrawals/suspensions. The dynamic nature of regulatory processes for pharmaceuticals risk management is still present on today’s exciting pharmacovigilance landscape and future regulatory standardization and increased collaboration is necessary to further help in reducing redundancy and support the review/assessment processes for the benefit of regulators, pharmaceutical industries and the patients

A critical review

Publisher Copyright: Copyright © 2022 Teixeira, Ferreira, Pereira-da-Silva and Ferreira.Atherosclerotic disease is a major cause of morbidity and mortality worldwide. Atherosclerosis may be present in different arterial territories and as a single- or multi-territorial disease. The different phenotypes of atherosclerosis are attributable only in part to acquired cardiovascular risk factors and genetic Mendelian inheritance. miRNAs, which regulate the gene expression at the post-transcriptional level, may also contribute to such heterogeneity. Numerous miRNAs participate in the pathophysiology of atherosclerosis by modulating endothelial function, smooth vascular cell function, vascular inflammation, and cholesterol homeostasis in the vessel, among other biological processes. Moreover, miRNAs are present in peripheral blood with high stability and have the potential to be used as non-invasive biomarkers for the diagnosis of atherosclerosis. However, the circulating miRNA profile may vary according to the involved arterial territory, considering that atherosclerosis expression, including the associated molecular phenotype, varies according to the affected arterial territory. In this review, we discuss the specific circulating miRNA profiles associated with atherosclerosis of different arterial territories, the common circulating miRNA profile of stable atherosclerosis irrespective of the involved arterial territory, and the circulating miRNA signature of multi-territorial atherosclerosis. miRNAs may consist of a simple non-invasive method for discriminating atherosclerosis of different arterial sites. The limitations of miRNA profiling for such clinical application are also discussed.publishersversionpublishe

MSCs Conditioned Media and Umbilical Cord Blood Plasma Metabolomics and Composition.

Human mesenchymal stem cells (hMSCs) from umbilical cord (UC) blood (UCB) and matrix are tested clinically for a variety of pathologies but in vitro expansion using culture media containing fetal bovine serum (FBS) is essential to achieve appropriate cell numbers for clinical use. Human UCB plasma (hUCBP) can be used as a supplement for hMSCs culture, since UCB is rich in soluble growth factors and due to worldwide increased number of cryopreserved UCB units in public and private banks, without the disadvantages listed for FBS. On the other hand, the culture media enriched in growth factors produced by these hMSCs in expansion (Conditioned medium--CM) can be an alternative to hMSCs application. The CM of the hMSCs from the UC might be a better therapeutic option compared to cell transplantation, as it can benefit from the local tissue response to the secreted molecules without the difficulties and complications associated to the engraftment of the allo- or xeno-transplanted cells. These facts drove us to know the detailed composition of the hUCBP and CM, by 1H-NMR and Multiplexing LASER Bead Technology. hUCBP is an adequate alternative for the FBS and the CM and hUCBP are important sources of growth factors, which can be used in MSCs-based therapies. Some of the major proliferative, chemotactic and immunomodulatory soluble factors (TGF-β, G-CSF, GM-CSF, MCP-1, IL-6, IL-8) were detected in high concentrations in CM and even higher in hUCBP. The results from 1H-NMR spectroscopic analysis of CM endorsed a better understanding of hMSCs metabolism during in vitro culture, and the relative composition of several metabolites present in CM and hUCBP was obtained. The data reinforces the potential use of hUCBP and CM in tissue regeneration and focus the possible use of hUCBP as a substitute for the FBS used in hMSCs in vitro culture

Impact of Gender in Predictive Value for Heart Transplantation Listing

BACKGROUND: Exercise testing is key in the risk stratification of patients with heart failure (HF). There are scarce data on its prognostic power in women. Our aim was to assess the predictive value of the heart transplantation (HTx) thresholds in HF in women and in men. METHODS: Prospective evaluation of HF patients who underwent cardiopulmonary exercise testing (CPET) from 2009 to 2018 for the composite endpoint of cardiovascular mortality and urgent HTx. RESULTS: A total of 458 patients underwent CPET, with a composite endpoint frequency of 10.5% in females vs. 16.0% in males in 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percent of predicted pVO2 were independent discriminators of the composite endpoint, particularly in women. The International Society for Heart Lung Transplantation recommended values of pVO2 ≤ 12 mL/kg/min or ≤14 if the patient is intolerant to β-blockers, VE/VCO2 slope > 35, and percent of predicted pVO2 ≤ 50% showed a higher diagnostic effectiveness in women. Specific pVO2, VE/VCO2 slope and percent of predicted pVO2 cut-offs in each sex group presented a higher prognostic power than the recommended thresholds. CONCLUSION: Individualized sex-specific thresholds may improve patient selection for HTx. More evidence is needed to address sex differences in HF risk stratification.publishersversionpublishe

Still a Powerful Tool?

Background: New therapies with prognostic benefits have been recently introduced in heart failure with reduced ejection fraction (HFrEF) management. The aim of this study was to evaluate the prognostic power of current listing criteria for heart transplantation (HT) in an HFrEF cohort submitted to cardiopulmonary exercise testing (CPET) between 2009 and 2014 (group A) and between 2015 and 2018 (group B). Methods: Consecutive patients with HFrEF who underwent CPET were followed-up for cardiac death and urgent HT. Results: CPET was performed in 487 patients. The composite endpoint occurred in 19.4% of group A vs. 7.4% of group B in a 36-month follow-up. Peak VO2 (pVO2) and VE/VCO2 slope were the strongest independent predictors of mortality. International Society for Heart and Lung Transplantation (ISHLT) thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers) and VE/VCO2 slope > 35 presented a similar and lower Youden index, respectively, in group B compared to group A, and a lower positive predictive value. pVO2 ≤ 10 mL/kg/min and VE/VCO2 slope > 40 outperformed the traditional cut-offs. An ischemic etiology subanalysis showed similar results. Conclusion: ISHLT thresholds showed a lower overall prognostic effectiveness in a contemporary HFrEF population. Novel parameters may be needed to improve risk stratification.publishersversionpublishe

Cell Therapy with Human MSCs Isolated from the Umbilical Cord Wharton Jelly Associated to a PVA Membrane in the Treatment of Chronic Skin Wounds

3. Departmento de Patologia e de Imunologia Molecular, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto (UP)

Insights from CardioMEMS™

Publisher Copyright: © 2024 Sociedade Portuguesa de CardiologiaIntroduction and objectives: Left ventricular global longitudinal strain (LVGLS) is an indicator of myocardial function in patients with heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). Nevertheless, it is not clear whether LVGLS correlates with filling pressures and cardiac output (CO) in an ambulatory setting. We aimed to assess whether LVGLS is associated with invasive pulmonary artery pressures (PAP) and CO in outpatients using the invasive remote monitoring CardioMEMS™ system. Methods: This single-center, prospective observational study included patients with HFrEF undergoing remote monitoring using the CardioMEMS™ system, between January 2020 and December 2022. Repeated transthoracic echocardiography (TTE) studies were performed in each patient and invasive hemodynamic data were obtained during the TTE studies using the CardioMEMS™ system. Univariate and multivariate models were used to assess the potential association between LVGLS and invasive PAP and CO. Results: Twelve patients were included and 46 TTE studies were analyzed. LVGLS was correlated with diastolic (d) PAP (r=0.403, p=0.041) and CO (r=−0.426, p=0.039) in the univariate analysis. In multivariate models, LVGLS was an independent predictor of dPAP and CO, but not mean PAP or systolic PAP. The variation of LVGLS between TTE studies was correlated with the variation of dPAP during follow-up (r=0.60, p=0.017). Conclusions: In a cohort of HFrEF patients under invasive hemodynamic remote monitoring, LVGLS was independently associated with invasive filling pressures and CO, in an outpatient setting. These findings reinforce the value of LVGLS for the management of outpatients with HFrEF.proofepub_ahead_of_prin

Influenza seroprotection correlates with predominant circulating viruses during 2014/15 and 2015/16 seasons in Portugal

Rede Portuguesa de Laboratórios para o Diagnóstico da GripeBACKGROUND: Population immune profile for influenza is highly affected by circulating influenza viruses, thus changing the risk of infection for influenza. This study aims to assess influenza immunity in the Portuguese population by age groups, during 2014 and 2015 and establish a relationship between seroprotection and circulating influenza viruses in 2014/15 and 2015/16 seasons. METHODS: Two cross-sectional studies were developed based on a convenience serum sample collected in June 2014 (n=626) and July 2015 (n=675) in hospitals from mainland and Azores and Madeira.Serums equally represent all age groups. Antibody titers were evaluated by HI assay for strains recommended for seasonal influenza vaccine northern hemisphere,2014/15 and 2015/2016. Seroprevalences were estimated for each strain by age group and the association with seasonal cumulative influenza-like illness (ILI) rates for influenza virus during both seasons was analised. RESULTS: In June 2014 the highest seroprotection was observed for influenza A(H3) (39.0%; 95% CI: 36.2-43.8%) and A(H1)pdm09 (29.7; 95% CI: 26.3-33.4%), with higher levels in children 5-14 years old. In 2014/2015 a dominant circulation of influenza B/Yamagata was observed with high incidence rates in individuals under 65 years old, the ones that had lower seroprotection. Although before the start of the season high protection for A(H3) was observed, the circulation of the new drift A(H3) strains had gained an immunological advantage,in accordance with A(H3) elevated incidence rates observed during 2014/15. In July 2015 the highest seroprotection was observed for influenza B/ Yamagata (55.1%; 95% CI: 51.4-58.9%), 2.4 times the estimated 2014.This increase was even more pronounced in younger (≤ 4 years old), 6.3 times increase in 2015.This fact is in agreement with the predominant influenza B virus detected and the high ILI incidence rate observed in children during 2014/2015 epidemic. Seroprotection levels for influenza A in July 2015 were not significantly different from 2014.During 2015/16 season, influenza A(H1N1)pdm09 was predominant, with high incidence rate in < 65 year old. Influenza B/Victoria lineage,although detected at low levels increased in frequency, in agreement with the lowest level of seroprotection detected in the general population before the start of 2015/2016 season (21.8%; 95% CI: 18.7-24.0%). CONCLUSIONS There was a correlation between virus circulation, incidence rates for each age group and the previous seroprotection for seasonal influenza viruses.Our study highlights the value of measuring the serological profile for influenza to establishe risk groups for infection for which an increase preventive measures, including vaccination, should be fostered.info:eu-repo/semantics/publishedVersio

SARS-CoV-2 introductions and early dynamics of the epidemic in Portugal

Genomic surveillance of SARS-CoV-2 in Portugal was rapidly implemented by the National Institute of Health in the early stages of the COVID-19 epidemic, in collaboration with more than 50 laboratories distributed nationwide. Methods By applying recent phylodynamic models that allow integration of individual-based travel history, we reconstructed and characterized the spatio-temporal dynamics of SARSCoV-2 introductions and early dissemination in Portugal. Results We detected at least 277 independent SARS-CoV-2 introductions, mostly from European countries (namely the United Kingdom, Spain, France, Italy, and Switzerland), which were consistent with the countries with the highest connectivity with Portugal. Although most introductions were estimated to have occurred during early March 2020, it is likely that SARS-CoV-2 was silently circulating in Portugal throughout February, before the first cases were confirmed. Conclusions Here we conclude that the earlier implementation of measures could have minimized the number of introductions and subsequent virus expansion in Portugal. This study lays the foundation for genomic epidemiology of SARS-CoV-2 in Portugal, and highlights the need for systematic and geographically-representative genomic surveillance.We gratefully acknowledge to Sara Hill and Nuno Faria (University of Oxford) and Joshua Quick and Nick Loman (University of Birmingham) for kindly providing us with the initial sets of Artic Network primers for NGS; Rafael Mamede (MRamirez team, IMM, Lisbon) for developing and sharing a bioinformatics script for sequence curation (https://github.com/rfm-targa/BioinfUtils); Philippe Lemey (KU Leuven) for providing guidance on the implementation of the phylodynamic models; Joshua L. Cherry (National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health) for providing guidance with the subsampling strategies; and all authors, originating and submitting laboratories who have contributed genome data on GISAID (https://www.gisaid.org/) on which part of this research is based. The opinions expressed in this article are those of the authors and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States government. This study is co-funded by Fundação para a Ciência e Tecnologia and Agência de Investigação Clínica e Inovação Biomédica (234_596874175) on behalf of the Research 4 COVID-19 call. Some infrastructural resources used in this study come from the GenomePT project (POCI-01-0145-FEDER-022184), supported by COMPETE 2020 - Operational Programme for Competitiveness and Internationalisation (POCI), Lisboa Portugal Regional Operational Programme (Lisboa2020), Algarve Portugal Regional Operational Programme (CRESC Algarve2020), under the PORTUGAL 2020 Partnership Agreement, through the European Regional Development Fund (ERDF), and by Fundação para a Ciência e a Tecnologia (FCT).info:eu-repo/semantics/publishedVersio