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Background: Recently, Europe has seen an emergence of mosquito-borne viruses (MBVs). Understanding citizens' perceptions of and behaviours towards mosquitoes and MBVs is crucial to reduce disease risk. We investigated and compared perceptions, knowledge, and determinants of citizens' behavioural intentions related to mosquitoes and MBVs in the Netherlands and Spain, to help improve public health interventions. Methods: Using the validated MosquitoWise survey, data was collected through participant panels in Spain (N = 475) and the Netherlands (N = 438). Health Belief Model scores measuring behavioural intent, knowledge, and information scores were calculated. Confidence Interval-Based Estimation of Relevance was used, together with potential for change indexes, to identify promising determinants for improving prevention measure use. Results: Spanish participants' responses showed slightly higher intent to use prevention measures compared to those of Dutch participants (29.1 and 28.2, respectively, p 0.03). Most participants in Spain (92.2%) and the Netherlands (91.8%) indicated they used at least one prevention measure, but differences were observed in which types they used. More Spanish participants indicated to have received information on mosquitoes and MBVs compared to Dutch participants. Spanish participants preferred health professional information sources, while Dutch participants favoured government websites. Determinants for intent to use prevention measures included "Knowledge", "Reminders to Use Prevention Measures", and "Information" in the Netherlands and Spain. Determinants for repellent use included "Perceived Benefits" and "Cues to Action", with "Perceived Benefits" having a high potential for behavioural change in both countries. "Self-Efficacy" and "Knowledge" were determinants in both countries for breeding site removal. Conclusion: This study found differences in knowledge between the Netherlands and Spain but similarities in determinants for intent to use prevention measures, intent to use repellents and intent to remove mosquito breeding sites. Identified determinants can be the focus for future public health interventions to reduce MBV risks. [ABSTRACT FROM AUTHOR]

Background: Worldwide, non-pharmaceutical interventions (NPIs) were implemented during the COVID-19 crisis, which heavily impacted the daily lives of citizens. This study considers public perspectives on whether and how public engagement (PE) can contribute to future decision-making about NPIs. Methods: An online survey was conducted among a representative sample of the public in the Netherlands from 27 October to 9 November 2021. Perceptions and preferences about PE in decision-making on NPIs to control COVID-19 were collected. Preferences regarding four NPIs were studied: Nightly curfew (NC); Digital Covid Certificate (DCC); Closure of elementary schools and daycares (CED); and physical distancing (1.5M). Engagement was surveyed based on the five participation modes of the IAP2 Spectrum of Public Participation, namely inform, consult, advice, collaborate and empower. Results: Of the 4981 respondents, 25% expressed a desire to engage in decision-making, as they thought engagement could improve their understanding and the quality of NPIs, as well as increase their trust in the government. Especially for the NPIs DCC and NC, respondents found it valuable to engage and provide their perspective on trade-offs in values (e.g. opening up society versus division in society by vaccination status). Respondents agreed that the main responsibility in decision-making should stay with experts and policy-makers. 50% of respondents did not want to engage, as they felt no need to engage or considered themselves insufficiently knowledgeable. Inform was deemed the most preferred mode of engagement, and empower the least preferred mode of engagement. Conclusion: We reveal large variations in public preferences regarding engagement in NPI decision-making. With 25% of respondents expressing an explicit desire to engage, and considering the benefit of PE in other areas of (public) health, opportunities for PE in NPI decision-making might have been overlooked during the COVID-19 pandemic. Our results provide guidance into when and how to execute PE in future outbreaks. [ABSTRACT FROM AUTHOR]

Aims: The aims of the study were to explore the impact of caring for patients carrying multi‐drug resistant organisms on nursing staff and identify factors predicting their intention to use personal protective equipment and their ability to comply with advised infection prevention and control measures. Background: Carriage of multi‐drug resistant organisms and corresponding infection prevention and control measures have a major impact on patients. Limited research has been done to investigate the impact of caring for these patients on nursing staff. Design: A cross‐sectional design. Methods: Online survey among Dutch nursing staff in various healthcare settings. Prediction analyses were conducted using random forest. The STROBE checklist was used preparing the manuscript. Results: 974 respondents were included. The majority of nursing staff reported to have experience in caring for patients carrying multi‐drug resistant organisms. Relevant dilemmas in daily practice were identified. Important predictors of the intention to use protective equipment were practicing hand hygiene, usable protocols, favourable attitudes and perceptions, as well as knowledge. Important predictors of the ability to comply with advised measures were usable and findable protocols, a suitable work environment and practicing hand hygiene. Conclusion: We have gained comprehensive insight into experiences, attitudes, perceptions, knowledge and dilemmas in daily practice of nursing staff caring for patients carrying multi‐drug resistant organisms. To enhance their intention to use protective equipment and their ability to comply with advised measures, activities should focus on improving hand hygiene and the usability of protocols. Additionally, efforts are needed to improve knowledge, provide better resources and a more supportive work environment. All of which need to be specifically tailored to each healthcare setting. Relevance to clinical practice: The results can be used in the development of interventions to improve nursing care while reducing the unfavourable impact on nursing staff and supporting adherence to advised measures. [ABSTRACT FROM AUTHOR]

The increasing life expectancy leads to more older adults suffering from infectious diseases. Vaccines are available against diverse infections such as influenza, pneumococcal disease, herpes zoster and tetanus. However, vaccine acceptance is crucial for optimal preventive effect. The objective of the study is to perform a cross-country analysis of the perceptions and decision-making behaviour of older adults regarding vaccinations and their information needs. Focus groups with older adults were conducted in four countries: France, Hungary, Italy and the Netherlands. Data were analysed using thematic analysis. Demographic characteristics of participants were gathered with a questionnaire. Influenza and tetanus vaccines were commonly known, as was the disease influenza. On the contrary, the awareness of the vaccines against pneumococcal disease and herpes zoster were low. Participants also expressed a need for more information on vaccines, such as possible side effects, contra-indications and duration of protection, emphasizing that information is a condition for decision-making on vaccination. General practitioners were found to be the most important in information provision on vaccines. Perceptions on vaccines, such as effectiveness, side effects and safety, as well as perceptions on infectious diseases, such as severity, susceptibility and experiencing an infectious disease, played a role in the decision-making of older adults on vaccines. More awareness of the information needs among older adults with regard to vaccines should be raised among general practitioners and other healthcare providers. This requires appropriate knowledge about the vaccines among healthcare providers as well as communication skills to meet the information needs of older adults. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has disproportionately affected persons in long-term care, who often experience health disparities. To delineate the COVID-19 disease burden among persons with intellectual disabilities, we prospectively collected data from 36 care facilities for 3 pandemic waves during March 2020-May 2021. We included outcomes for 2,586 clients with PCR-confirmed SARS-CoV-2 infection, among whom 161 had severe illness and 99 died. During the first 2 pandemic waves, infection among persons with intellectual disabilities reflected patterns observed in the general population, but case-fatality rates for persons with intellectual disabilities were 3.5 times higher and were elevated among those ≥40 years of age. Severe outcomes were associated with older age, having Down syndrome, and having ≥1 concurrent condition. Our study highlights the disproportionate COVID-19 disease burden among persons with intellectual disabilities and the need for disability-inclusive research and policymaking to inform disease surveillance and public health policies for this population. [ABSTRACT FROM AUTHOR]

Background: In the management of epidemics, like COVID‐19, trade‐offs have to be made between reducing mortality and morbidity and minimizing socioeconomic and political consequences. Traditionally, epidemic management (EM) has been guided and executed attentively by experts and policymakers. It can, however, still be controversial in the public sphere. In the last decades, public engagement (PE) has been successfully applied in various aspects of healthcare. This leads to the question if PE could be implemented in EM decision‐making. Methods: From June to October 2020, seven deliberative discussion focus groups were executed with 35 Dutch citizens between 19 and 84 years old. Their views on PE in COVID‐19 management were explored. The deliberative approach allows for the education of participants on the topic before the discussion. The benefits, barriers, timing and possible forms of PE in EM were discussed. Results: Almost all participants supported PE in EM, as they thought that integrating their experiences and ideas would benefit the quality of EM, and increase awareness and acceptance of measures. A fitting mode for PE was consultation, as it was deemed important to provide the public with possibilities to share ideas and feedback; however, final authority remained with experts. The publics could particularly provide input about communication campaigns and control measures. PE could be executed after the first acute phase of the epidemic and during evaluations. Conclusions: This paper describes the construction of an empirically informed framework about the values and conditions for PE in EM from the perspective of the public. Participants expressed support to engage certain population groups and considered it valuable for the quality and effectiveness of EM; however, they expressed doubts about the feasibility of PE and the capabilities of citizens. In future studies, these results should be confirmed by a broader audience. Patient or Public Contribution: No patients or members of the public were involved in the construction and execution of this study. This study was very exploratory, to gain a first insight into the views of the public in the Netherlands, and will be used to develop engagement practices accordingly. At this stage, the involvement of the public was not yet appropriate. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, all women aged 30–60 years are invited to participate in the national cervical cancer screening programme, which is aimed at early detection and treatment of precancerous lesions. One fourth of the Dutch population has a migration background, with Turkish and Moroccan immigrants being the largest immigrant populations. Turkish‐ and Moroccan‐Dutch women show lower screening participation rates and a higher incidence of cervical cancer, compared to native Dutch women. Since current information materials are not tailored to these women's needs, we developed a short culturally sensitive educational video to facilitate informed decision‐making for cervical cancer screening among Turkish‐ and Moroccan‐Dutch women. This article describes the development process of this video and the lessons learned. Methods: Using the Entertainment–Education communication strategy, we collaborated with an interdisciplinary team of Turkish‐ and Moroccan‐Dutch women, researchers, public health experts, and creative media professionals. We developed the video following the different stages of the Media Mapping model: Orientation, Crystallization, Design/Production, Implementation, and Dissemination. Each stage is described in the paper. Results: The video was developed in Moroccan‐Arabic, ‐Berber and Turkish, and emphasized three main themes: (1) more certainty about having cervical (pre)cancer and the possibility to prevent treatment, surgery, or premature death, and because of this, being there for the children, (2) according to the Islam, a woman should take good care of her health, and (3) anxiety, shame, and privacy. Conclusions: A short culturally sensitive educational video, delivered as part of a larger intervention together with the current information brochure, was developed based on theory and grounded in the needs of Turkish‐ and Moroccan‐Dutch women. The value and effectiveness of this intervention to facilitate informed cervical cancer screening decisions are evaluated in a randomised controlled trial. Patient or Public Contribution: We collaborated with Turkish‐ and Moroccan‐Dutch women during the development process of a short culturally sensitive educational video. Turkish‐ and Moroccan‐Dutch women were also invited to watch the raw footage to verify whether the content and presentation matched their needs and requirements. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Whether the lower Dutch cervical cancer (CC) screening participation of Turkish- and Moroccan-Dutch women is based on informed decision-making is unknown. Our aim was to explore how and why Turkish- and Moroccan-Dutch women decide to participate or not in the current Dutch CC screening programme as well as to learn their perceptions on self-sampling. DESIGN: Six focus group discussions were conducted between March and April 2019 with Turkish (n = 24) and Moroccan (n = 20) women in the Netherlands, aged 30–60 years. Questions were based on an extended version of the Health Belief Model. Discussions were transcribed verbatim and thematically analysed. RESULTS: Participants lacked knowledge about CC and its screening, and seemed to be unaware of the cons of CC screening. Perceived barriers for screening were lack of a good command of the Dutch language, having a male general practitioner, fatalism, shame and taboo, and associations of CC with lack of femininity and infertility. Other barriers were fear of the test result, cancer, suffering, death, and leaving their children behind after death. Perceived facilitators were a high perceived severity of disease, social support, and short procedure time. An additional religious facilitator included the responsibility to take care of one's own health using medical options that God provided. Participants had low self-efficacy expectations towards performing correct self-sampling. CONCLUSIONS: Although participants' informed-decision making seems to be limited, this study showed that women do not only consider factual medical information, but also practical, emotional, cultural, and religious aspects prior to deciding to screen or not. Information materials should be tailored to these aspects, as well as translated to appropriate languages due to lack of a good command of the Dutch language. Self-efficacy expectations towards performing correct self-sampling should be enhanced to promote informed CC screening participation among Turkish- and Moroccan-Dutch women. [ABSTRACT FROM AUTHOR]

This study aims to increase insights into the potential role of the media in the amplification and attenuation of modern risks in society, by studying the dynamics and contents of the newspaper coverage about the potential health risk posed by rubber granulate in the Netherlands. We thematically analysed 153 national newspaper articles about the risks posed by rubber granulate between September 2016 and February 2017. Our results suggest that newspaper coverage might have contributed to heightened public risk perceptions by presenting the negligible health risk as uncertain, focusing on controversy between authorities and experts, describing responses such as concerns, commotion, and adopted risk mitigation measures by members of the public, and by providing insufficient contextualization on whether hazardous substances in rubber granulate pose a threat to health. The risks posed by rubber granulate is one of the many modern risks that has become subject to heated and mediated public discussions. Our results provide in-depth insights into important content elements in media coverage during such discussions and the impact of these elements on public perceptions. Public health institutes and other authorities might be able to mitigate the amplification of risks through media coverage by means of appropriate preparedness and response. [ABSTRACT FROM AUTHOR]

Background: To counter the rise in invasive meningococcal disease (IMD) serogroup W, the Netherlands introduced a menACWY catch-up vaccination campaign for teenagers in 2018 and 2019. Teenagers and parents who have questions or who seek advice from a professional about vaccinations are likely to consult a youth healthcare professional or their general practitioner. This study aimed to appraise the ability of these healthcare professionals to meet the information needs of teenagers and their parents at the start of the vaccination campaign.Methods: With online surveys, we assessed information needs in teenagers (N = 1603) and parents (N = 1784) concerning IMD and the menACWY vaccination, and in healthcare professionals (N = 520) in their communication with teenagers and parents. We additionally studied healthcare professionals' expectations of the information needs of teenagers and parents.Results: We identified several information needs about IMD and the menACWY vaccination in teenagers, parents and healthcare professionals. Some important commonalities in the information needs in these three groups were found, with regard to the topics IMD prevention, vaccine effectiveness and vaccine protection duration. Healthcare professionals' expectations of the information needs of teenagers and parents were quite accurate but some important discrepancies were found.Conclusion: Our results suggest that healthcare professionals might not have been optimally equipped or prepared for questions from teenagers and their parents at the beginning of the vaccination campaign. We recommend public health institutes to timely assess and meet information needs about new vaccines in healthcare professionals to optimally equip them for consultations. [ABSTRACT FROM AUTHOR]

A key component of outbreak control is monitoring public perceptions and public response. To determine public perceptions and public responses during the first 3 months of the coronavirus disease (COVID-19) outbreak in the Netherlands, we conducted 6 repeated surveys of ≈3,000 persons. Generalized estimating equations analyses revealed changes over time as well as differences between groups at low and high risk. Overall, respondents perceived the risks associated with COVID-19 to be considerable, were positive about the mitigation measures, trusted the information and the measures from authorities, and adopted protective measures. Substantial increases were observed in risk perceptions and self-reported protective behavior in the first weeks of the outbreak. Individual differences were based mainly on participants' age and health condition. We recommend that authorities constantly adjust their COVID-19 communication and mitigation strategies to fit public perceptions and public responses and that they tailor the information for different groups. [ABSTRACT FROM AUTHOR]

To control the rise in Neisseria meningitidis strain W infections, during 2018-2019, the Netherlands launched a catch-up meningococcal conjugate (MenACWY) vaccination campaign for teenagers (13-18 years of age). Applying a mental models approach, we surveyed teenagers and their parents about their knowledge and beliefs about meningococcal disease, the MenACWY vaccination, vaccinations in general, and their MenACWY vaccination intentions. Using random forest analysis, we studied predictions of vaccination intentions by knowledge and beliefs. Survey response rate was 52.8% among teenagers and 59.4% among parents. MenACWY vaccination intentions were best predicted by knowledge and beliefs about vaccinations in general, surpassing knowledge and beliefs about meningococcal disease and the MenACWY vaccination. For teenagers, their parents' intention that the teenager be vaccinated was a strong predictor of the teenagers' own vaccination intention. To optimize vaccination uptake during future outbreaks, we recommend that communications emphasize the effectiveness and safety of vaccines and continue to focus on parents. [ABSTRACT FROM AUTHOR]

Background: Carriers of methicillin-resistant Staphylococcus aureus (MRSA) experience a variety of personal and social consequences, despite the asymptomatic nature of carriage. Some of these consequences are inherent to the application in practice of strict infection prevention guidelines. However, the experiences of nurses carrying MRSA have not been documented. This study aimed to describe the experiences of nurses carrying MRSA to get insight into the impact of MRSA carriage on nurses in a country with a "search-and-destroy" policy for MRSA. Methods: A qualitative study was conducted among eighteen nurses who experienced MRSA carriage and were working in healthcare organizations in the Netherlands (e.g. hospitals, nursing homes and home care). Semi-structured interviews were conducted using an interview guide. The interviews were audio tape recorded, transcribed and analyzed using thematic analysis. Results: MRSA carriage has an impact on the life of nurses during four distinct phases: becoming aware of carrying MRSA, processing information and guidance, experiencing consequences of carriage and, when applicable, a life after eradication of MRSA. Each phase was found to be associated with negative consequences. The impact of MRSA carriage on the daily life of nurses is mostly influenced by the experience of consequences of MRSA carriage – including a ban to work with patients, eradication treatment with antibiotics, and social isolation from others – despite the asymptomatic nature of MRSA carriage itself. In addition, lack of information and guidance increased the impact of carriage. Conclusions: This study shows nurses experience various consequences of MRSA carriage, despite the asymptomatic nature of carriage. The work ban, eradication treatment and social isolation influenced the nurses' work-related future, personal health and social environment. The impact of carriage may be reduced by clear information and guidance, and support from others. Therefore, sufficient information and guidance needs to be given to MRSA carriers by healthcare organizations. [ABSTRACT FROM AUTHOR]

Background. As demonstrated during the global Ebola crisis of 2014–2016, healthcare institutions in high resource settings need support concerning preparedness during threats of infectious disease outbreaks. This study aimed to exploratively develop a standardized preparedness system to use during unfolding threats of severe infectious diseases. Methods. A qualitative three-step study among infectious disease prevention and control experts was performed. First, interviews (n = 5) were conducted to identify which factors trigger preparedness activities during an unfolding threat. Second, these triggers informed the design of a phased preparedness system which was tested in a focus group discussion (n = 11). Here preparedness activities per phase and per healthcare institution were identified. Third, the preparedness system was completed and verified in individual interviews (n = 3). Interviews and the focus group were recorded, transcribed, and coded for emerging themes by two researchers independently. Data were analyzed using content analysis. Results. Four preparedness phases were identified: preparedness phase green is a situation without the presence of the infectious disease threat that requires centralized care, anywhere in the world. Phase yellow is an outbreak in the world with some likelihood of imported cases. Phase orange is a realistic chance of an unexpected case within the country, or unrest developing among population or staff; phase red is cases admitted to hospitals in the country, potentially causing a shortage of resources. Specific preparedness activities included infection prevention, diagnostics, patient care, staff, and communication. Consensus was reached on the need for the development of a preparedness system and national coordination during threats. Conclusions. In this study, we developed a standardized system to support institutional preparedness during an increasing threat. Use of this system by both curative healthcare institutions and the (municipal) public health service, could help to effectively communicate and align preparedness activities during future threats of severe infectious diseases. [ABSTRACT FROM AUTHOR]

In this study, we test to what extent an educational video on the intricacies of antibiotic resistance affects public attitudes towards antibiotic resistance and how such information is absorbed by the most likely targets of public health campaigns. We use a representative sample of 2037 individuals (from 2016) to test how people respond to a video educating them about antibiotic resistance. Our results show that receiving information does increase the general awareness of antibiotic resistance among our respondents. Yet, these effects are most profound for those who are the most likely targets of such information: the least knowledgeable group and those who have a more apathetic worldview. Our results are in line with suggestions made by the knowledge deficit model and show that the influence of cultural predispositions on the uptake of information about antibiotic resistance should not be ignored in future campaigns. [ABSTRACT FROM AUTHOR]

The recent epidemic of Ebola virus disease (EVD) resulted in countries worldwide to prepare for the possibility of having an EVD patient. In this study, we estimate the costs of Ebola preparedness and response borne by the Dutch health system. An activity-based costing method was used, in which the cost of staff time spent in preparedness and response activities was calculated based on a time-recording system and interviews with key professionals at the healthcare organizations involved. In addition, the organizations provided cost information on patient days of hospitalization, laboratory tests, personal protective equipment (PPE), as well as the additional cleaning and disinfection required. The estimated total costs averaged €12.6 million, ranging from €6.7 to €22.5 million. The main cost drivers were PPE expenditures and preparedness activities of personnel, especially those associated with ambulance services and hospitals. There were 13 possible cases clinically evaluated and one confirmed case admitted to hospital. The estimated total cost of EVD preparedness and response in the Netherlands was substantial. Future costs might be reduced and efficiency increased by designating one ambulance service for transportation and fewer hospitals for the assessment of possible patients with a highly infectious disease of high consequences. [ABSTRACT FROM AUTHOR]

Background: The Ebola outbreak in West-Africa triggered risk communication activities to promote adequate preventive behaviour in the Netherlands. Our study investigated the level of knowledge, perceptions, and media use regarding Ebola.Methods: In December 2014, an online questionnaire was administered to the Dutch population (n = 526) and Health Care Workers (HCW) (n = 760).Results: The mean knowledge score (range 0-15) of HCW (m = 13.3;SD = 1.4) was significantly higher than the general public (m = 10.8;SD = 2.0). No significant difference was found in perceived severity and susceptibility. Perceived fear of the general public (m = 2.5; SD = 0.8) was significantly higher than among HCW (m = 2.4; SD = 0.7). Respondents primarily used television to obtain information.Conclusions: While Ebola was perceived severe, it did not lead to excessive fear or perceived susceptibility for developing the disease. Nonetheless, our research showed that knowledge with respect to human-to-human transmission is low, while this is crucial to complying with preventive measures. Our study reveals priorities for improving risk communication. [ABSTRACT FROM AUTHOR]

Background: Preparedness is considered essential for healthcare organizations to respond effectively to outbreaks. In the current study we aim to capture the views of first responders on what they consider key recommendations for high quality preparedness. Furthermore, we identified the recommendations with the highest urgency from the perspective of first responders.Methods: We chose a multistep approach using a systematic Delphi procedure. Previously extracted recommendations from scientific literature were presented to a national and two international expert panels. We asked the experts to score the recommendations based on relevance for high quality preparedness. In addition we asked them to choose the ten most urgent recommendations.Results: Starting with 80 recommendations from scientific literature, 49 key recommendations were selected by both international expert panels. Differences between both panels were mainly on triage protocols. In addition, large differences were found in the selection of the ten most urgent recommendations.Conclusions: In this study infectious disease experts selected a set of key recommendations representing high quality preparedness and specified which ones should be given the highest urgency when preparing for a future crisis. These key recommendations can be used to shape their preparedness activities. [ABSTRACT FROM AUTHOR]

Background: Long-term fatigue with detrimental effects on daily functioning often occurs following acute Q-fever. Following the 2007–2010 Q-fever outbreak in the Netherlands with over 4000 notified cases, the emphasis on long-term consequences of Q-fever increased. The aim of this study was to provide an overview of all relevant available literature, and to identify knowledge gaps regarding the definition, diagnosis, background, description, aetiology, prevention, therapy, and prognosis, of fatigue following acute Q-fever. Design: A systematic review was conducted through searching Pubmed, Embase, and PsycInfo for relevant literature up to 26th May 2015. References of included articles were hand searched for additional documents, and included articles were quality assessed. Results: Fifty-seven articles were included and four documents classified as grey literature. The quality of most studies was low. The studies suggest that although most patients recover from fatigue within 6–12 months after acute Q-fever, approximately 20% remain chronically fatigued. Several names are used indicating fatigue following acute Q-fever, of which Q-fever fatigue syndrome (QFS) is most customary. Although QFS is described to occur frequently in many countries, a uniform definition is lacking. The studies report major health and work-related consequences, and is frequently accompanied by nonspecific complaints. There is no consensus with regard to aetiology, prevention, treatment, and prognosis. Conclusions: Long-term fatigue following acute Q-fever, generally referred to as QFS, has major health-related consequences. However, information on aetiology, prevention, treatment, and prognosis of QFS is underrepresented in the international literature. In order to facilitate comparison of findings, and as platform for future studies, a uniform definition and diagnostic work-up and uniform measurement tools for QFS are proposed. [ABSTRACT FROM AUTHOR]

Objectives: Since few pandemics have occurred since the Spanish influenza pandemic, we should learn from every (mild) pandemic that occurs. The objective of this study was to report on general practitioners’ and practice assistants’ acceptance of the chosen national policy, and experiences in the Netherlands during the influenza A(H1N1)pdm09 pandemic. Methods: Data on experience and acceptance of the chosen national policy were obtained by structured questionnaires for general practitioners (n = 372) and practice assistants (n = 503) in April 2010. Results: The primary policy chosen for general practice was not always accepted and complied with by general practitioners, although the communication (of changes) and collaboration with involved organisations were rated as positive. In particular, the advised personal protective measures were difficult to implement in daily work and thus not executed by 44% of general practitioners. Half of the general practitioners were not satisfied with the patient information provided by the government. The influenza A(H1N1) pandemic highly impacted on general practitioners’ and practice assistants’ workloads, which was not always deemed to be adequately compensated. Discussion: Involvement of general practitioners in future infectious disease outbreaks is essential. This study addresses issues in the pandemic policy which might be critical in a more severe pandemic. [ABSTRACT FROM AUTHOR]

Background: In 2011, a unique Q fever vaccination campaign targeted people at risk for chronic Q fever in the southeast of the Netherlands. General practitioners referred patients with defined cardiovascular risk-conditions (age >15 years). Prevalence rates of those risk-conditions were lacking, standing in the way of adequate planning and coverage estimation. We aimed to obtain prevalence rates retrospectively in order to estimate coverage of the Q fever vaccination campaign. Methods: With broad search terms for these predefined risk-conditions, we extracted patient-records from a large longitudinal general-practice research-database in the Netherlands (IPCI-database). After validation of these records, obtained prevalence rates (stratified for age and sex) extrapolated to the Q fever high-incidence area population, gave an approximation of the size of the targeted patient-group. Coverage calculation addressed people actually screened by a pre-vaccination Q fever skin test and serology (coverage) and patients referred by their general practitioners (adjusted-coverage) in the 2011 campaign. Results: Our prevalence estimate of any risk-condition was 3.1% (lower-upper limits 2.9-3.3%). For heart valve defects, aorta aneurysm/prosthesis, congenital anomalies and endocarditis, prevalence was 2.4%, 0.6%, 0.4% and 0.1%, respectively. Estimated number of eligible people in the Q fever high-incidence area was 11,724 (10,965-12,532). With 1330 people screened for vaccination, coverage of the vaccination campaign was 11%. For referred people, the adjusted coverage was 18%. Coverage was lowest among the very-old and highest for people aged 50–70 years. Conclusion: The estimated coverage of the vaccination campaign was limited. This should be interpreted in the light of the complexity of this target-group with much co-morbidity, and of the vaccine that required invasive pre-vaccination screening. Calculation of prevalence rates of risk-conditions based on the IPCI-database was feasible. This procedure proved an efficient tool for future use, when prevalence estimates for policy, implementation or surveillance of subgroup-vaccination or other health-care interventions are needed. [ABSTRACT FROM AUTHOR]

Background Food-borne Salmonella infections are a worldwide concern. During a large-scale outbreak, it is important that the public follows preventive advice. To increase compliance, insight in how the public gathers its knowledge and which factors determine whether or not an individual complies with preventive advice is crucial. Methods In 2012, contaminated salmon caused a large Salmonella Thompson outbreak in the Netherlands. During the outbreak, we conducted an online survey (n = 1,057) to assess the general public's perceptions, knowledge, preventive behavior and sources of information. Results Respondents perceived Salmonella infections and the 2012 outbreak as severe (m = 4.21; five-point scale with 5 as severe). Their knowledge regarding common food sources, the incubation period and regular treatment of Salmonella (gastro-enteritis) was relatively low (e.g., only 28.7% knew that Salmonella is not normally treated with antibiotics). Preventive behavior differed widely, and the majority (64.7%) did not check for contaminated salmon at home. Most information about the outbreak was gathered through traditional media and news and newspaper websites. This was mostly determined by time spent on the medium. Social media played a marginal role. Wikipedia seemed a potentially important source of information. Conclusions To persuade the public to take preventive actions, public health organizations should deliver their message primarily through mass media. Wikipedia seems a promising instrument for educating the public about food-borne Salmonella. [ABSTRACT FROM AUTHOR]

After an imported case of Marburg hemorrhagic fever was reported in 2008 in the Netherlands, control measures to prevent transmission were implemented. To evaluate consequences of these measures, we administered a structured questionnaire to 130 contacts classified as either having high-risk or low-risk exposure to body fluids of the case-patient; 77 (59.2%) of 130 contacts responded. A total of 67 (87.0%) of 77 respondents agreed that temperature monitoring and reporting was necessary, significantly more often among high-risk than low-risk contacts (p<0.001). Strict compliance with daily temperature monitoring decreased from 80.5% (62/77) during week 1 to 66.2% (51/77) during week 3. Contacts expressed concern about development of Marburg hemorrhagic fever (58.4%, 45/77) and infecting a family member (40.2%, 31/77). High-risk contacts had significantly higher scores on psychological impact scales (p<0.001) during and after the monitoring period. Public health authorities should specifically address consequences of control measures on the daily life of contacts. [ABSTRACT FROM AUTHOR]

On July 10, 2008, Marburg hemorrhagic fever was confirmed in a Dutch patient who had vacationed recently in Uganda. Exposure most likely occurred in the Python Cave (Maramagambo Forest), which harbors bat species that elsewhere in Africa have been found positive for Marburg virus. A multidisciplinary response team was convened to perform a structured risk assessment, perform risk classi- fication of contacts, issue guidelines for follow-up, provide information, and monitor the crisis response. In total, 130 contacts were identified (66 classified as high risk and 64 as low risk) and monitored for 21 days after their last possible exposure. The case raised questions specific to international travel, postexposure prophylaxis for Marburg virus, and laboratory testing of contacts with fever. We present lessons learned and results of the follow-up serosurvey of contacts and focus on factors that prevented overreaction during an event with a high public health impact. [ABSTRACT FROM AUTHOR]

Notification of 2 imported cases of infection with Middle East respiratory syndrome coronavirus in the Netherlands triggered comprehensive monitoring of contacts. Observed low rates of virus transmission and the psychological effect of contact monitoring indicate that thoughtful assessment of close contacts is prudent and must be guided by clinical and epidemiologic risk factors. [ABSTRACT FROM AUTHOR]

Background: The likelihood of large-scale outbreaks of multidrug-resistant organisms (MDRO) is growing. MDRO outbreaks can affect a wide range of healthcare institutions. Control of such outbreaks requires structured collaboration between professionals from all involved healthcare institutions, but guidelines for cross-institutional procedures are, however, often missing. Literature indicates that such multi-actor collaboration is most promising when effective network brokers are present, and when the collaborative actors have clarity about the different roles and responsibilities in the outbreak response network, including collaborative structures and coordination roles. Studying these factors in an imaginary MDRO outbreak scenario, we gained insights into the expectations that health professionals in the Netherlands have in regard to the procedures required to best respond to any future cross-institutional MDRO outbreaks.Methods: For exploration purpose, a focus group discussion with ten healthcare professionals was held. Subsequently, an online-survey was conducted among 56 healthcare professionals in two Dutch regions. The survey data was analysed using social network analyses (clique analysis and centrality analysis), which provided insights into the collaborative structures and potential brokers in the outbreak response networks. Additionally, respondents were asked which healthcare institutions and which professions they would prefer as coordinating actors in the collaborative network.Results: Our results show a relatively high level of perceived clarity about the roles and responsibilities that healthcare professionals have during a joint outbreak response. The regional outbreak response networks which were studied appeared inclusive and integrated, with many overlapping groups of fully-connected healthcare actors. Social network analyses resulted in the identification of several central actors from different healthcare institutions with the potential to take on a brokerage role in the collaboration. Actors in the outbreak response networks also showed to prefer several healthcare professionals to take on the coordination roles.Conclusion: Expected collaborative structures during an imaginary regional MDRO outbreak response are relatively dense and integrated. In regard to the coordination of an MDRO outbreak response, based on both the network analysis results and the preferred coordination roles, our findings support a governance structure with several healthcare institutions involved in responding to future cross-institutional MDRO outbreaks. [ABSTRACT FROM AUTHOR]

Background: In November 2016, the Dutch Health Council recommended hepatitis B (HBV) screening for first-generation immigrants from HBV endemic countries. However, these communities show relatively low attendance rates for screening programmes, and our knowledge on their participation behaviour is limited. We identified determinants associated with the intention to request an HBV screening test in first-generation Moroccan-Dutch immigrants. We also investigated the influence of non-refundable costs for HBV screening on their intention.Methods: Offline and online questionnaires were distributed among first- and second/third-generation Moroccan-Dutch immigrants using respondent-driven sampling. Random forest analyses were conducted to determine which determinants had the greatest impact on (1) the intention to request an HBV screening test on one's own initiative, and (2) the intention to participate in non-refundable HBV screening at €70,-.Results: Of the 379 Moroccan-Dutch respondents, 49.3% intended to request a test on their own initiative, and 44.1% were willing to attend non-refundable screening for €70,-. Clarity regarding infection status, not having symptoms, fatalism, perceived self-efficacy, and perceived risk of having HBV were the strongest predictors to request a test. Shame and stigma, fatalism, perceived burden of screening participation, and social influence of Islamic religious leaders had the greatest predictive value for not intending to participate in screening at €70,- non-refundable costs. Perceived severity and possible health benefit were facilitators for this intention measure. These predictions were satisfyingly accurate, as the random forest method retrieved area under the curve scores of 0.72 for intention to request a test and 0.67 for intention to participate in screening at €70,- non-refundable costs.Conclusions: By the use of respondent-driven sampling, we succeeded in studying screening behaviour among a hard-to-reach minority population. Despite the limitations associated with correlated data and the sampling method, we recommend to (1) incorporate clarity regarding HBV status, (2) stress the risk of an asymptomatic infection, (3) emphasise mother-to-child transmission as the main transmission route, and (4) team up with Islamic religious leaders to help decrease elements of fatalism, shame, and stigma to enhance screening uptake of Moroccan immigrants in the Netherlands. [ABSTRACT FROM AUTHOR]

In spring 2021, several countries, among which the Netherlands, suspended vaccinations against COVID-19 with the Vaxzevria vaccine from AstraZeneca after reports of rare but severe adverse events. This study investigates the influence of this suspension on the Dutch public's perceptions of COVID-19 vaccinations, trust in the government's vaccination campaign, and COVID-19 vaccination intentions. We conducted two surveys in a population of general Dutch public (18 +), one shortly before the pause of AstraZeneca vaccinations and one shortly thereafter (N eligible for analysis = 2628). Our results suggest no changes in perceptions nor intentions regarding the COVID-19 vaccines in general but do suggest a decline in trust in the government's vaccination campaign. In addition, after the suspension, perceptions of the AstraZeneca vaccines were more negative in comparison to those of COVID-19 vaccinations in general. AstraZeneca vaccination intentions were also considerably lower. These results stress the need to adapt vaccination policies to anticipated public perceptions and responses following a vaccine safety scare, as well as the importance of informing citizens about the possibility of very rare adverse events prior to the introduction of novel vaccines. [ABSTRACT FROM AUTHOR]

The integration of different types of knowledge in epistemically hierarchical settings remains one of the greatest challenges when developing standards for healthcare practices. In this article, we open up the notion of knowledge integration and empirically examine the various ways in which different types of knowledge interact and can be integrated. To allow us to focus on the diverse forms of knowledge as well as their interaction and integration, we combine Moreira's work on repertoires of evaluation with that of Dewulf and Bouwen on frame interactions. We examine the quest for knowledge integration by studying interactions in the case of the development of the COVID-19 vaccination guideline in the Netherlands, a prime example of the encounter of a wide range and diversity of knowledge that needs to be appraised and integrated into guideline recommendations. Drawing on ethnographic observations of more than 70 guideline development meetings between 2021 and 2022, we first map the different types of knowledge and reasonings used by the guideline developers and subsequently analyze their interactions. We identified eight knowledge interaction patterns, being disconnection, polarization, accommodation, incorporation, reconnection, reconciliation, passive juxtaposition, and kaleidoscopic integration. We hereby draw attention to the various possible knowledge interactions encompassed in the concept of "knowledge integration", especially to those in which integration is achieved while differences and incompatibilities are maintained. Finally, we discuss potential ways to facilitate fruitful knowledge interactions during collaborative work which include the ability to accept and sustain tensions between different types of knowledge and making more explicit use of frame or rather repertoire reflection. • The paper explores knowledge integration when developing healthcare standards. • COVID-19 vaccination guideline developers needed to combine diverse knowledge. • Different types of knowledge can interact and be integrated in a variety of ways. • Kaleidoscopic integration' enables integration without resolving differences. • Awareness of conversational practices can foster generative knowledge interactions. [ABSTRACT FROM AUTHOR]

Highlights: [•] 1368 patients at high risk for Q fever vaccination were vaccinated. [•] The Q fever vaccine was rather reactogenic but safe in these high-risk patients. [•] Q fever vaccination program for high-risk patients was challenging but successful. [•] Clarity on roles and responsibilities is necessary for a multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Abstract: This study examines patient''s reasons for accepting Q fever vaccination, including risk perception, feelings of doubt, social influence, information-seeking behavior, preventive measures taken, and perceptions regarding received information and governmental action. Data was obtained from exit interviews conducted after Q fever vaccination, between January and April 2011. A total of 413 patients with specific cardiovascular conditions in the Netherlands participated in exit interviews; 70% were older than 60 years. Most reported reasons for accepting Q fever vaccination were: “I am at an increased risk for developing (chronic) Q fever” (69%) and “my general practitioner recommends Q fever vaccination for me” (34%). The majority (86%) reported a high perceived severity of Q fever, and only 6% felt vulnerable to Q fever after vaccination. One-third had doubts about getting vaccinated, primarily related to fears of side effects and practical barriers. Fifty-two percent solicited advice from their social networks; of these, 67% reported influence on their vaccination decision. General practitioners and family were the most reported sources of advice. Thirty percent actively sought information about Q fever vaccination. Twenty-two percent of all respondents had taken other preventive measures, such as avoiding contact with goats and sheep (74%), and cancelling or postponing visits to Q fever-affected areas (36%). Almost one-half of all respondents reported negative feelings regarding governmental action to control Q fever. Significant differences were observed regarding feelings of doubt, information-seeking behavior, perceived vulnerability, preventive measures taken, and perceptions regarding received information and governmental action regarding gender, age, educational level, and/or employment status. Vaccination decision-making may differ among socio-demographic subgroups. When preparing future vaccination campaigns, it is important to obtain greater insight into these differences and take these aspects into account in risk communication strategies by tailoring information to specific target groups. [Copyright &y& Elsevier]

Background: Contact tracing (CT) is a key intervention to contain outbreaks of communicable diseases. During large-scale outbreaks, public health services may lack the resources required to perform CT effectively. One way of mitigating this issue is to shift some of the tasks in CT normally performed by public health services to cases and their contacts, supported by digital tools. We refer to this as "self-led CT." However, while the effectiveness of the self-led CT inherently depends on the willingness and skills of citizens to participate, the determinants of citizens' intention to participate in self-led CT are not yet fully understood., Objective: We aimed to identify determinants of Dutch citizens' intention to participate in self-led CT and assess their potential for behavioral change, so as to identify "behavior change targets," which may be used in the development and implementation of self-led CT to increase citizens' intention to participate., Methods: In March 2022, we performed an online cross-sectional questionnaire study. The questionnaire was developed based on findings from a previous exploratory semistructured interview study and distributed among a Dutch consumer panel. Using all questionnaire items as potential predictors, we performed a random forest analysis to identify determinants of citizens' intention to participate in self-led CT. We then performed an Agglomerative Hierarchical Cluster Analysis to identify groups of related determinants that may be considered overarching behavior change targets. Finally, we used Confidence Interval-Based Estimation of Relevance and calculated the Potential for Change Indices to compare the potential for behavioral change of the selected individual determinants and determinant clusters., Results: The questionnaire was completed by 3019 respondents. Our sample is representative of the Dutch population in terms of age, gender, educational level, and area of residence. Out of 3019 respondents, 2295 (76%) had a positive intention to participate in self-led CT. We identified 20 determinants of citizens' intention that we grouped into 9 clusters. In general, increasing citizens' trust in the digital tools developed for self-led CT has the highest potential to increase citizens' intention, followed by increasing the belief that using digital tools makes participating in self-led CT easier, reducing privacy-related concerns, and increasing citizens' willingness-and sense of responsibility-to cooperate in CT in general., Conclusions: Overall, Dutch citizens are positive toward participating in self-led CT. Our results provide directions for the development and implementation of self-led CT, which may be particularly useful in preparing for future, large-scale outbreaks., (©Yannick Bernd Helms, Akke van der Meer, Rik Crutzen, José António Ferreira, Mirjam E E Kretzschmar, Aura Timen, Nora Hamdiui, Mart L Stein. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 30.10.2024.)

During the COVID-19 pandemic, public groups mobilised themselves in civil-society engagement practices (CSEPs) aiming to improve or suggest alternative epidemic management. This study explores the motivation to establish CSEPs and their perceived contributions to epidemic management, to gain insight whether integrating views of CSEPs could add value. A systematic online search was executed to identify CSEPs focused on COVID-19 management between January 2020 and January 2022 in the Netherlands. In order to create a comprehensible overview of the identified CSEPs, relevant characteristics were gathered and mapped, for example, local or national scope, subject of action and goals. A selection of CSEPs was interviewed between April and June 2022 to study their motivators to start the CSEPs and perceived contributions to management. The search resulted in the identification of 22 CSEPs, of which members of 14 CSEPs were interviewed. These members indicated several issues that motivated the start of their CSEP, namely; shortage of equipment, sense of solidarity, and a perceived lack of governmental action, lack of democratic values and lack in diversity of perspectives in epidemic management. All respondents believed to have contributed to policy or society, by influencing opinions, and occasionally by altering policy. However, respondents encountered obstacles in their attempts to contribute such as inability to establish contact with authorities, feeling unheard or undermined, and complications due to the interplay of political interests. In conclusion, CSEPs have fulfilled various roles such as providing alternative management policies, producing equipment, representing the needs of vulnerable populations, and supporting citizens and providing citizens with other viewpoints and information. The identified motivators to establish CSEPs in this study uncover room for improvements in policy. These insights, together with the identified perceived barriers of CSEPs, can be used to improve the connection between (future) epidemic management and public priorities and interests., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In the Netherlands, since 1996, a national cervical cancer (CC) screening program has been implemented for women aged 30 to 60 years. Regional screening organizations send an invitation letter and information brochure in Dutch to the home addresses of targeted women every 5 years. Although this screening is free of charge, Turkish- and Moroccan-Dutch women, especially, show low screening participation and limited informed decision-making (IDM). As Turkish- and Moroccan-Dutch women indicated their need for information on the practical, emotional, cultural, and religious aspects of CC screening, we developed a culturally sensitive educational video (CSEV) as an addition to the current information brochure., Objective: In this study, we aimed to evaluate the added effect of the CSEV on IDM regarding CC screening participation among Turkish and Moroccan women aged 30 to 60 years in the Netherlands through a randomized intervention study., Methods: Initial respondents were recruited via several social media platforms and invited to complete a web-based questionnaire. Following respondent-driven sampling, respondents were asked to recruit a number of peers from their social networks to complete the same questionnaire. Respondents were randomly assigned to the control (current information brochure) or intervention condition (brochure and CSEV). We measured respondents' knowledge and attitude regarding CC screening and their intention to participate in the next CC screening round before and after the control or intervention condition. We evaluated the added effect of the CSEV (above the brochure) on their knowledge, attitude, intention, and IDM using intention-to-treat analyses., Results: The final sample (n=1564) included 686 (43.86%) Turkish and 878 (56.14%) Moroccan-Dutch women. Of this sample, 50.7% (793/1564) were randomized to the control group (350/793, 44.1% Turkish and 443/793, 55.9% Moroccan) and 49.3% (771/1564) to the intervention group (336/771, 43.6% Turkish and 435/771, 56.4% Moroccan). Among the Turkish-Dutch women, 33.1% (116/350) of the control respondents and 40.5% (136/336) of the intervention respondents consulted the brochure (not statistically significant). Among Moroccan-Dutch women, these percentages were 28.2% (125/443) and 37.9% (165/435), respectively (P=.003). Of all intervention respondents, 96.1% (323/336; Turkish) and 84.4% (367/435; Moroccan) consulted the CSEV. The CSEV resulted in more positive screening attitudes among Moroccan-Dutch women than the brochure (323/435, 74.3% vs 303/443, 68.4%; P=.07). Women, who had never participated in CC screening before, showed significantly more often a positive attitude toward CC screening compared with the control group (P=.01)., Conclusions: Our short and easily implementable CSEV resulted in more positive screening attitudes, especially in Moroccan-Dutch women. As the CSEV was also watched far more often than the current brochure was read, this intervention can contribute to better reach and more informed CC screening decisions among Turkish- and Moroccan-Dutch women., Trial Registration: International Clinical Trial Registry Platform NL8453; https://tinyurl.com/2dvbjxvc., (©Nora Hamdiui, Mart L Stein, Jim van Steenbergen, Rik Crutzen, Martine Bouman, Abresham Khan, Miyase N Çetin, Aura Timen, Maria van den Muijsenbergh. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.10.2022.)

Early detection of and treatment for chronic Q fever might prevent potentially life-threatening complications. We performed a chronic Q fever screening program in general practitioner practices in the Netherlands 10 years after a large Q fever outbreak. Thirteen general practitioner practices located in outbreak areas selected 3,419 patients who had specific underlying medical conditions, of whom 1,642 (48%) participated. Immunofluorescence assay of serum showed that 289 (18%) of 1,642 participants had a previous Coxiella burnetii infection (IgG II titer >1:64), and 9 patients were suspected of having chronic Q fever (IgG I y titer >1:512). After medical evaluation, 4 of those patients received a chronic Q fever diagnosis. The cost of screening was higher than estimated earlier, but the program was still cost-effective in certain high risk groups. Years after a large Q fever outbreak, targeted screening still detected patients with chronic Q fever and is estimated to be cost-effective.

Background: From 2015 to 2018, the Netherlands faced an outbreak of invasive meningococcal disease (IMD) caused by serogroup W. To counter the rise in infections, the government introduced a catch-up menACWY vaccination campaign for teenagers in 2018 and 2019. The outbreak situation induced substantial media attention and a run on menACWY vaccines outside the vaccination campaign. This study aimed to gain insights into the dynamics of public perceptions of and responses to the outbreak and the menACWY vaccination, and into the media coverage about the outbreak., Methods: Three repeated surveys (N = 1110) between 2017 and 2019 were sent to parents of teenagers invited for a menACWY catch-up vaccination, other parents, and individuals with no under-age children. These surveys assessed IMD risk perceptions, attitudes towards the menACWY vaccination, trust in involved institutions, and willingness to vaccinate with the menACWY vaccine. Changes in the public perceptions and responses were studied with linear multilevel regression analyses. In addition, 103 national newspaper articles from the period 2017-2019 were thematically coded with themes about IMD and the menACWY vaccination., Results: The survey results showed clear increases in perceived IMD severity, positive attitude towards the menACWY vaccination, and willingness to vaccinate over time. Perceived IMD vulnerability remained low across all three waves, and trust in involved institutions increased slightly. Differences between the survey groups were limited. The newspaper articles discussed the rise in infections extensively, the disease symptoms, and the possible fatal outcome of IMD. In addition, while many articles discussed the menACWY vaccine shortage, few discussed the safety or effectiveness of the vaccine., Conclusion: The real-time insights into the interrelated dynamics of public perceptions, responses, and media coverage provide an integrated portrait of the social developments during this outbreak. The focus on IMD severity and the absence of doubt in the public discussion about vaccine safety may have played an important role in the societal response to this outbreak and the recommended vaccine., (© 2022. The Author(s).)

Background: 10 days after the first reported case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the Netherlands (on Feb 27, 2020), 55 (4%) of 1497 health-care workers in nine hospitals located in the south of the Netherlands had tested positive for SARS-CoV-2 RNA. We aimed to gain insight in possible sources of infection in health-care workers., Methods: We did a cross-sectional study at three of the nine hospitals located in the south of the Netherlands. We screened health-care workers at the participating hospitals for SARS-CoV-2 infection, based on clinical symptoms (fever or mild respiratory symptoms) in the 10 days before screening. We obtained epidemiological data through structured interviews with health-care workers and combined this information with data from whole-genome sequencing of SARS-CoV-2 in clinical samples taken from health-care workers and patients. We did an in-depth analysis of sources and modes of transmission of SARS-CoV-2 in health-care workers and patients., Findings: Between March 2 and March 12, 2020, 1796 (15%) of 12 022 health-care workers were screened, of whom 96 (5%) tested positive for SARS-CoV-2. We obtained complete and near-complete genome sequences from 50 health-care workers and ten patients. Most sequences were grouped in three clusters, with two clusters showing local circulation within the region. The noted patterns were consistent with multiple introductions into the hospitals through community-acquired infections and local amplification in the community., Interpretation: Although direct transmission in the hospitals cannot be ruled out, our data do not support widespread nosocomial transmission as the source of infection in patients or health-care workers., Funding: EU Horizon 2020 (RECoVer, VEO, and the European Joint Programme One Health METASTAVA), and the National Institute of Allergy and Infectious Diseases, National Institutes of Health., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

In late December 2019, a cluster of cases of pneumonia of unknown etiology were reported linked to a market in Wuhan, China 1 . The causative agent was identified as the species Severe acute respiratory syndrome-related coronavirus and was named SARS-CoV-2 (ref.  2 ). By 16 April the virus had spread to 185 different countries, infected over 2,000,000 people and resulted in over 130,000 deaths 3 . In the Netherlands, the first case of SARS-CoV-2 was notified on 27 February. The outbreak started with several different introductory events from Italy, Austria, Germany and France followed by local amplification in, and later also outside, the south of the Netherlands. The combination of near to real-time whole-genome sequence analysis and epidemiology resulted in reliable assessments of the extent of SARS-CoV-2 transmission in the community, facilitating early decision-making to control local transmission of SARS-CoV-2 in the Netherlands. We demonstrate how these data were generated and analyzed, and how SARS-CoV-2 whole-genome sequencing, in combination with epidemiological data, was used to inform public health decision-making in the Netherlands.

Background: To optimize the focus of future public information campaigns in The Netherlands promoting the uptake of vaccines among adults and children, we quantified the contribution of several attributes to the vaccination decision., Method: We performed a discrete choice experiment (DCE) among Dutch adults including six attributes, i.e. vaccine effectiveness, vaccine-preventable burden of disease (specified in severity and frequency), accessibility of vaccination in terms of co-payment and prescription requirements, frequency of mild side-effects, population-level vaccination coverage and local vaccination coverage among family and friends. Participants answered the DCE from their own perspective ('oneself' group) or with regard to a vaccine decision for their youngest child ('child' group). The data was analysed by means of panel mixed logit models., Results: We included 1547 adult participants (825 'oneself' and 722 'child'). Vaccine effectiveness was the most important attribute in the 'oneself' group, followed by burden of disease (relative importance (RI) 78%) and accessibility (RI 76%). In the 'child' group, burden of disease was most important, but tied closely with vaccine effectiveness (RI 97%). Of less importance was the risk of mild vaccine-related side-effects and both population and local vaccination coverage. Interestingly, participants were more willing to vaccinate when uptake among the population or family and friends was high, indicating that social influence and social norms plays a role., Conclusions: Vaccine effectiveness and disease severity are key attributes in vaccination decision-making for adults making a decision for themselves and for parents who decide for their children. Hence, public information campaigns for both adult and child vaccination should primarily focus on these two attributes. In addition, reinforcing social norms may be considered.

On 20 November 2019, Lassa fever was diagnosed in a physician repatriated from Sierra Leone to the Netherlands. A second physician with suspected Lassa fever, repatriated a few days later from the same healthcare facility, was confirmed infected with Lassa virus on 21 November. Comprehensive contact monitoring involving high- and low-risk contacts proved to be feasible and follow-up of the contacts did not reveal any case of secondary transmission in the Netherlands.

Background: Early detection, identification, and treatment of chronic hepatitis B through screening is vital for those at increased risk, e.g. born in hepatitis B endemic countries. In the Netherlands, Moroccan immigrants show low participation rates in health-related screening programmes. Since social networks influence health behaviour, we investigated whether similar screening intentions for chronic hepatitis B cluster within social networks of Moroccan immigrants., Methods: We used respondent-driven sampling (RDS) where each participant ("recruiter") was asked to complete a questionnaire and to recruit three Moroccans ("recruitees") from their social network. Logistic regression analyses were used to analyse whether the recruiters' intention to request a screening test was similar to the intention of their recruitees., Results: We sampled 354 recruiter-recruitee pairs: for 154 pairs both participants had a positive screening intention, for 68 pairs both had a negative screening intention, and the remaining 132 pairs had a discordant intention to request a screening test. A tie between a recruiter and recruitee was associated with having the same screening intention, after correction for sociodemographic variables (OR 1.70 [1.15-2.51])., Conclusions: The findings of our pilot study show clustering of screening intention among individuals in the same network. This provides opportunities for social network interventions to encourage participation in hepatitis B screening initiatives.

To rapidly assess possible community transmission in Noord-Brabant, the Netherlands, healthcare workers (HCW) with mild respiratory complaints and without epidemiological link (contact with confirmed case or visited areas with active circulation) were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Within 2 days, 1,097 HCW in nine hospitals were tested; 45 (4.1%) were positive. Of six hospitals with positive HCW, two accounted for 38 positive HCW. The results informed local and national risk management.

Background: The emergence and spread of multidrug resistant microorganisms is a serious threat to transnational public health. Therefore, it is vital that cross-border outbreak response systems are constantly prepared for fast, rigorous, and efficient response. This research aims to improve transnational collaboration by identifying, visualizing, and exploring two cross-border response networks that are likely to unfold during outbreaks involving the Netherlands and Germany., Methods: Quantitative methods were used to explore response networks during a cross-border outbreak of carbapenem resistant Enterobacteriaceae in healthcare settings. Eighty-six Dutch and German health professionals reflected on a fictive but realistic outbreak scenario (response rate ≈ 70%). Data were collected regarding collaborative relationships between stakeholders during outbreak response, prior working relationships, and trust in the networks. Network analysis techniques were used to analyze the networks on the network level (density, centralization, clique structures, and similarity of tie constellations between two networks) and node level (brokerage measures and degree centrality)., Results: Although stakeholders mainly collaborate with stakeholders belonging to the same country, transnational collaboration is present in a centralized manner. Integration of the network is reached, since several actors are beneficially positioned to coordinate transnational collaboration. However, levels of trust are moderately low and prior-existing cross-border working relationships are sparse., Conclusion: Given the explored network characteristics, we conclude that the system has a promising basis to achieve effective coordination. However, future research has to determine what kind of network governance form might be most effective and efficient in coordinating the necessary cross-border response activity. Furthermore, networks identified in this study are not only crucial in times of outbreak containment, but should also be fostered in times of non-crisis., Competing Interests: The authors have declared that no competing interests exist.

This paper reports on the perceptions of risk related to practicing sports on fields containing rubber granulate infill, and preferences for mitigation measures, among people with and without offspring exposed to rubber granulate. Two repeated surveys were conducted among members of the general population and parents of children aged under 18, in the middle of a dynamic public discussion about the potential health risks of exposure to rubber granulate. The first survey (N = 1033) was administered in December 2016 at a time characterized by considerable public uncertainty and contrasting opinions in the public risk debate. The second survey (N = 782) was conducted in January 2017 after the publication of a risk assessment report, which concluded that practicing sport on fields containing rubber granulate is safe. Multilevel analyses were performed to study changes in perceptions of risk and mitigation preferences in the time between the two surveys, the influence of being familiar with new information following the risk assessment report, and the differences in the perceptions of risk and mitigation preferences between groups with and without offspring exposed to rubber granulate. The results of this study show that, initially, a substantial proportion of the Dutch public perceived practicing sports on fields containing rubber granulate as a potential health threat to children. Over time, after publication of a new risk assessment study stating that practicing sports on fields containing rubber granulate is safe, perceived risk and preferences for mitigation of this risk decreased, especially among those who were familiar with the new information. Parents of children under the age of 18, in particular those with children who were exposed to rubber granulate, were more likely to perceive the risk as higher and to prefer a stricter mitigation policy. These insights may be important to inform public health communication strategies with respect to the timing and tailoring of risk messages to various groups.

A seasonal reassortant A(H1N2) influenza virus harbouring genome segments from seasonal influenza viruses A(H1N1)pdm09 (HA and NS) and A(H3N2) (PB2, PB1, PA, NP, NA and M) was identified in March 2018 in a 19-months-old patient with influenza-like illness (ILI) who presented to a general practitioner participating in the routine sentinel surveillance of ILI in the Netherlands. The patient recovered fully. Further epidemiological and virological investigation did not reveal additional cases.

Background: In 2013 the Netherlands faced a measles epidemic, during which more than 2600 individuals were infected, including 19 health care workers (HCW). Vaccinating health care workers can lead to benefits on both the individual and public health level, underscoring the need for HCW vaccination. In June of 2013 the Dutch National Institute for Public Health and the Environment (RIVM) developed a measles guideline (MG) that advised Dutch hospitals to strengthen their policies concerning measles vaccination of HCWs. A key problem with guidelines, however, is adherence, which can be due to several barriers. The objective of this research was to identify the barriers that Dutch hospital professionals encountered during the implementation of this policy guideline, in order to improve the implementation of similar policies in the future., Methods: In-depth interviews (n = 9) were conducted with 12 hospital health care professionals involved with prevention and control of communicable diseases. These participants represented ten different Dutch hospitals located in eight of the twelve different provinces. Participants were asked about their experiences during the 2013-2014 measles epidemic regarding infection prevention measures, including vaccination of HCWs, with a specific focus on barriers to the implementation of the RIVM guideline., Results: The implementation of the MG was impeded by several (types of) barriers. First, barriers were found related to knowledge and attitude, and included lack of agreement, barriers associated with leadership and issues related to evidence-based decision making. Second, barriers related to characteristics of the guideline, mostly related to unclear or missing guideline content. Finally, contextual and social factors such as human and financial resources, belief systems, physical facilities and technical support, and national views on vaccination policies also play an important role in policy implementation., Conclusions: This study has provided valuable insights into the barriers infection prevention specialists encounter during the implementation of new policies concerning vaccination of HCWs in times of a major outbreak. Moreover, this study exposed the complexity and breadth of barriers that are of importance when implementing vaccination policies in the hospital setting. In order to improve the implementation of similar policies in the future, guideline developers and health care providers and administrators alike should aim to eliminate or minimise these identified barriers by taking into account the suggestions made by the authors.

Background: Following a large Q fever outbreak in the Netherlands, patients at risk for chronic Q fever received a whole-cell Q fever vaccine. Sensitized people were excluded based on pre-vaccination screening with skin test (ST) and serology. An investigational IFN-γ-production assay was added. No previous experience existed for Q fever vaccination in this patient risk-group with predefined cardiac valvular anomalies or aortic aneurysm/prosthesis and many co-morbidities. We studied the adverse events (AE) and their association with patient characteristics and immunological parameters., Methods: AE registration covered the week after skin test and 90 days following vaccination, with the use of diaries, interviews and spontaneous reports. Serious (S)AE were assessed immediately to ensure safety. We coded AE according to reported severity. Univariate and multivariate analysis addressed associations., Results: Pre-vaccination screening led to exclusion of 182 patients with positive serology and 207 patients with positive skin test-reading. The skin test did not lead to any causally related SAE. Subsequent vaccination of 1370 patients did not reveal unexpected AE; however, 80% of vaccinees reported local AE (in 26% of these pronounced or extensive). The two causally related SAE (0.1%) both concerned a persistent subcutaneous injection site mass. AE were more frequent in women, younger patients, and those without immunosuppressive co-morbidity/medication. The occurrence of local AE after skin test was associated with pre-vaccination positive serology and high IFN-γ production. This was also true for local AE following vaccination, with a strong association with local AE after skin test as well. The proportion of vaccinees with positive serology and positive IFN-γ values 6 months after vaccination was higher in those with local AE after skin test or after vaccination (non-significant, probably due to small numbers)., Conclusion: Q fever vaccination was safe but reactogenic in this high-risk patient-group. Rates of local AE were higher in women, younger age groups and in those with positive immunological parameters. Vaccinees with local AE after skin test or after vaccination appear to have more pronounced post-vaccination immune responses.

Background: In contrast to seasonal influenza epidemics, where the majority of deaths occur amongst elderly, a considerable part of the 2009 pandemic influenza related deaths concerned relatively young people. In the Netherlands, all deaths associated with laboratory-confirmed influenza A(H1N1) 2009 virus infection had to be notified, both during the 2009-2010 pandemic season and the 2010-2011 influenza season. To assess whether and to what extent pandemic mortality patterns were reverting back to seasonal patterns, a retrospective analyses of all notified fatal cases associated with laboratory-confirmed influenza A(H1N1) 2009 virus infection was performed., Methods: The notification database, including detailed information about the clinical characteristics of all notified deaths, was used to perform a comprehensive analysis of all deceased patients with a laboratory-confirmed influenza A(H1N1) 2009 virus infection. Characteristics of the fatalities with respect to age and underlying medical conditions were analysed, comparing the 2009-2010 pandemic and the 2010-2011 influenza season., Results: A total of 65 fatalities with a laboratory-confirmed influenza A(H1N1) 2009 virus infection were notified in 2009-2010 and 38 in 2010-2011. During the pandemic season, the population mortality rates peaked in persons aged 0-15 and 55-64 years. In the 2010-2011 influenza season, peaks in mortality were seen in persons aged 0-15 and 75-84 years. During the 2010-2011 influenza season, the height of first peak was lower compared to that during the pandemic season. Underlying immunological disorders were more common in the pandemic season compared to the 2010-2011 season (p = 0.02), and cardiovascular disorders were more common in the 2010-2011 season (p = 0.005)., Conclusions: The mortality pattern in the 2010-2011 influenza season still resembled the 2009-2010 pandemic season with a peak in relatively young age groups, but concurrently a clear shift toward seasonal patterns was seen, with a peak in mortality in the elderly, i.e. ≥ 75 years of age.

Enhanced surveillance of infections due to the pandemic A(H1N1) influenza virus, which included monitoring for antiviral resistance, was carried out in the Netherlands from late April 2009 through late May 2010. More than 1100 instances of infection with the pandemic A(H1N1) influenza virus from 2009 and 2010 [A(H1N1) 2009] distributed across this period were analyzed. Of these, 19 cases of oseltamivir-resistant virus harboring the H275Y mutation in the neuraminidase (NA) were detected. The mean 50% inhibitory concentration (IC50) levels for oseltamivir- and zanamivir-susceptible A(H1N1) 2009 viruses were 1.4-fold and 2-fold, respectively, lower than for the seasonal A(H1N1) influenza viruses from 2007/2008; for oseltamivir-resistant A(H1N1) 2009 virus the IC50 was 2.9-fold lower. Eighteen of the 19 patients with oseltamivir-resistant virus showed prolonged shedding of the virus and developed resistance while on oseltamivir therapy. Sixteen of these 18 patients had an immunodeficiency, of whom 11 had a hematologic disorder. The two other patients had another underlying disease. Six of the patients who had an underlying disease died; of these, five had received cytostatic or immunosuppressive therapy. No indications for onward transmission of resistant viruses were found. This study showed that the main association for the emergence of cases of oseltamivir-resistant A(H1N1) 2009 virus was receiving antiviral therapy and having drug-induced immunosuppression or an hematologic disorder. Except for a single case of a resistant virus not linked to oseltamivir therapy, the absence of detection of resistant variants in community specimens and in specimens from contacts of cases with resistant virus suggested that the spread of resistant A(H1N1) 2009 virus was limited. Containment may have been the cumulative result of impaired NA function, successful isolation of the patients, and prophylactic measures to limit exposure., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Enterohaemorrhagic Escherichia coli (EHEC) is a group of pathogenic Shiga toxin-producing E. coli that can cause haemorrhagic colitis and haemolytic uraemic syndrome (HUS). The disease usually occurs sporadically, but sometimes also occurs in large outbreaks such as that which recently occurred in northern Germany. EHEC infection is a zoonosis and its reservoir is in ruminant farm animals (cattle, sheep and goats). EHEC infection should be considered in patients with bloody diarrhoea, but in the course of many severe EHEC infections a picture resembling HUS may also occur. Antibiotic treatment is contraindicated because it does not reduce the duration of the disease and may have negative complications. Patients with EHEC infection may spread the bacteria and their care includes contact isolation measures with their own toilet facilities. The E. coli type O104:H4 that occurred in Germany has a combination of specific virulence characteristics. This outbreak affected many people who developed HUS and neurological symptoms following bloody diarrhoea.