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To gain insight into the spread of hepatitis B among various risk groups in Amsterdam a 6-year (1992‐1997) retrospective DNA sequencing study was carried out on isolates from stored sera from reported primary cases of acute hepatitis B infection. Cases were classified according to risk behavior, as determined in interviews. Of the available serum, a selected region of hepatitis B-virus-DNA was amplified and sequenced. The nucleotide alignments were subjected to phylogenetic tree analysis. When nucleotide alignments were subjected to phylogenetic analysis, the strains of 54 isolates, 26% of the 204 reported primary cases, clustered in five genotypes: A, C, D, E, and F. In genotype A, a cluster related to men having sex with men was identified. In genotype D, two subclusters could be identified: one was related to injecting drug use and another was related to the Moroccan population in Amsterdam. The remaining strains showed a high genetic variability within three different genotypes: F, E, and C. Of the 14 identical isolates in the ‘‘homosexual men cluster,’’ one was isolated from a female heterosexual. Of the 14 identical strains in the ‘‘drug users strain,’’ six were from non-drug using heterosexual active individuals. In the cluster of twelve isolates related to hepatitis B-endemic areas, probable modes of transmission were varied. Sequence analysis provides important insight into the spread of hepatitis B among various highrisk groups. The analysis indicates that the prevention strategy in The Netherlands fails to stop transmission of hepatitis B from persistently infected individuals originating from hepatitis Bendemic countries. J. Med. Virol. 66:159‐

Aims—To use laboratory data and liver biopsies, prospectively obtained from hepatitis B surface antigen (HBsAg) and anti hepatitis B e antigen (anti-HBe) positive patients, for the assessment of: (1) the relation between biopsy length/number of portal tracts and sampling error; (2) the relation between the severity of piecemeal necrosis and the new grading terminology (minimal, mild, moderate, and severe chronic hepatitis); and (3) liver pathology, which has not been studied in patients with this specific serological profile. Methods—The study group (n = 174) included 104 patients with normal aminotransferase concentrations and no cases with clinically apparent cirrhosis. The specimen length and number of portal tracts were measured at light microscopy examination. Sampling error analysis was related to the discrepancies between aminotransferase concentrations versus histological grade. Detailed histological scorings were undertaken by the reference pathologist and compared with laboratory and hepatitis B virus (HBV) DNA precore sequence data. Results—Sampling error seemed to be a constant feature, even for biopsies ≥ 20 mm, but increased dramatically in biopsies < 5 mm long and/or containing less than four portal tracts. Between 25% and 30% of biopsies, graded as "mild" or "moderate" activity showed features of moderate and severe piecemeal necrosis, respectively. Ten per cent of the patients with normal aminotransferase values had stage III–IV hepatic fibrosis, and 20% had piecemeal necrosis. Only cytoplasmic, not nuclear, core antigen expression was a strong predictor of high hepatitis B viraemia. There was no association between precore stop codon mutations, grade/stage of liver disease, and hepatitis B core antigen (HBcAg) expression. Conclusions—The specimen available for light microscopical examination should be > 5 mm long and should contain more than four portal tracts. In addition, the new grading terminology might give the clinician an inappropriately mild impression of the severity of piecemeal necrosis. Furthermore, even in the presence of normal aminotransferase concentrations, considerable liver pathology can be found in 10–20% of HBsAg and anti-HBe positive individuals; such pathology is not associated with the occurrence of precore stop codon mutations. Key Words: liver pathology • chronic hepatitis B virus infection • anti-hepatitis B antigen e positive • core antigen expression • serum hepatitis B virus DNA • hepatitis grading • sampling error

Self-reported compliance with a malaria chemoprophylaxis regimen of proguanil (PG) plus chloroquine (CQ) was assessed in a cohort of 547 Dutch travellers who visited a single travel clinic when travelling to various areas endemic for falciparum malaria. 503 (92%) had taken PG/CQ prophylaxis, but only 326 (60%) reported regular and uninterrupted use throughout the journey and 4 weeks afterwards. Compliance differed by travel destination and was 45% in South America, 52% in West Africa, 53% in South-east Asia, 60% in the Indian Subcontinent and 78% in East Africa. Parasitologically confirmed falciparum malaria occurred in 5 travellers (0.9%), including 3 of 24 non-compliant travellers to West Africa (12.5%). Apart from destination, independent risk factors for non-compliance were young age, extensive travel experience and adventurous travel. Compliance with protection against mosquito bites was 80% for wearing long-sleeved shirts and long-legged trousers after sunset, 73% for use of repellents, 56% for sleeping under bed nets and 37% for keeping the sleeping quarters free of mosquitoes. Although 440 travellers (80%) reported to have taken two or more of these measures at least once, only 88 (16%) had done so on a daily basis. Daily use of bed nets was reported more frequently among subjects who were non-compliant with chemoprophylaxis. Compliance regarding malaria chemoprophylaxis should be improved, particularly in high-risk areas such as Sub-saharan Africa, with extra attention to young, adventurous travellers. More emphasis should be placed on prevention of Anopheles bites.

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The serum antibody response to simultaneous administration of immune globulin (Ig) and an inactivated hepatitis A vaccine was investigated in healthy volunteers who had been tested and found free of hepatitis A virus. One hundred and forty nine subjects were randomly allocated into three groups. Group 1 received three doses of hepatitis A vaccine at 0, 1 and 6 months, group 2 received 5 ml of Ig and group 3 received a combination of Ig and vaccine. In group 3 the seropositivity rate measured by enzyme-linked immunosorbent assay was 100% at day 5, month 1 and 2, 96% at month 6 and again 100% at month 7. In the group that received vaccine alone the seroconversion rates were 0, 96, 100, 98 and 100 respectively. The geometric mean titres in subjects who received passive/active immunization were about twofold lower than in subjects who received vaccine alone, indicating interference of Ig with the immune response. Despite this, the data show that simultaneous administration of hepatitis A vaccine and Ig confers both immediate protection via Ig administration and long-term vaccine-induced protection. As the antibody levels reached are about twofold lower compared to that after administration of hepatitis A vaccine alone, a booster dose may be required sooner, than if the vaccine were administered alone.

Toen deze vragen mij ter beantwoording werden voorgelegd was er recent een werkgroep ‘DTP-vaccinatie voor reizigers’ geinstalleerd door het Landelijk Overleg Infectieziektenbestrijding (LOI). Het protocol dat door deze werkgroep is opgesteld zal nog moeten worden getoetst door het LOI. De verwachting is dat er inhoudelijk geen wijzigingen meer zullen worden aangebracht.

The objective of this study was to determine the hepatitis B surface antigen (HBsAg) prevalence in pregnant women in northwestern Romania in order to be able to formulate an adequate prevention policy on perinatal transmission of the hepatitis B virus. A cross-sectional serological survey was carried out among parturient women in 18 hospitals in this area in September 1991. Out of 2,354 parturient women, 90 (3.8%) were positive for HBsAg. The prevalence did not differ significantly by age, parity, rural versus urban residence or the district of residence. The prevalence did differ significantly according to the level of medical care. Women who gave birth in level 3 and 4 hospitals had a higher prevalence (5.1%) than those women who gave birth in level 1 and 2 hospitals (3.0%), supporting the assumption that iatrogenic infection has played an important role in the spread of hepatitis B virus (HBV) infection in Romania. Incorporation of universal vaccination with hepatitis B vaccine into the routine childhood immunization programme in Romania would be the best strategy to prevent perinatal transmission of HBV. Further studies are needed to validate the assumption that iatrogenic transmission has played an important role in the spread of HBV infection in Romania.

In the enhanced antenatal hepatitis B screening and neonatal immunization program in Amsterdam, 691 hepatitis B surface antigen (HBsAg) positive expectant mothers were reported in the period 1993-1998. The coverage of the screening was calculated at 97%. HBsAg-prevalence was high in women from Ghana and South-East Asia, and lowest in Dutch women. Hepatitis B immune globulin (HBIg) was administered within 24h to 95.9% of the neonates; 99.7% completed the vaccination series. About 6 weeks after the third vaccination the titer antiHBs was > or =100 IU/l in 85% of children; in 12% the titers were 10-100 IU/l; 3% had titers

OBJECTIVE--To study the incidence of pelvic inflammatory disease (PID) in Amsterdam in the period 1983-1990. METHODS--Patients diagnosed with PID based on a clinical definition were reported weekly by 30 general practices who covered 11% of the Amsterdam population. Annual age specific incidences were calculated using the number of women in the participating practices as the denominator. RESULTS--The PID incidence was approximately 50 per 10,000 women through 1986, and then started to decrease in 1987 to reach 24 per 10,000 in 1990. The decreasing trend since 1987 was seen in the age-groups 20-24, 25-34 and 35-44 years, but not among teenagers. The moment of decline coincided with extensive attention given in the Dutch media to the risk of heterosexual transmission of the human immunodeficiency virus (HIV). CONCLUSION--It is plausible that the declining incidence of PID was influenced by a change of heterosexual behaviour under the threat of AIDS.

To establish prevalence and aetiology of tinea capitis in children attending primary school in Amsterdam South-East.Prevalence survey.The Municipal Health Service Amsterdam, the Netherlands, selected classes of four primary schools in a survey with children clinically suspected of having tinea capitis as well as classes without clinical cases. Per school at least one class with a notified case was included. Written information was provided to all parents; the parents of three children refused participation. After clinical examination by a team of physicians and nursing staff scalp cultures were taken using the brush method from 315 children (aged 4-12 years) in 16 classes.The clinical diagnosis 'tinea capitis' was established in 25 children, significantly more in boys than in girls (relative risk (RR) = 2.92: 95% confidence interval (95% CI) 1.20-7.11). Of all children 7% had positive cultures, more boys than girls (RR = 3.13: 95% CI: 1.18-8.28). Symptomatic cases (confirmed by culture) amounted to 3.2% of all children. The carrier rate was 3.8%. Trichophyton tonsurans was the most frequently isolated dermatophyte both in symptomatic children and in carriers.In 7% of all children (3.2% with symptoms of tinea capitis, 3.8% without) dermatophytes were cultured from scalp samples, the main aetiologic agent being T. tonsurans.

OBJECTIVE: To establish prevalence and aetiology of tinea capitis in children attending primary school in Amsterdam South-East. DESIGN: Prevalence survey. METHODS: The Municipal Health Service Amsterdam, the Netherlands, selected classes of four primary schools in a survey with children clinically suspected of having tinea capitis as well as classes without clinical cases. Per school at least one class with a notified case was included. Written information was provided to all parents; the parents of three children refused participation. After clinical examination by a team of physicians and nursing staff scalp cultures were taken using the brush method from 315 children (aged 4-12 years) in 16 classes. RESULTS: The clinical diagnosis 'tinea capitis' was established in 25 children, significantly more in boys than in girls (relative risk (RR) = 2.92: 95% confidence interval (95% CI) 1.20-7.11). Of all children 7% had positive cultures, more boys than girls (RR = 3.13: 95% CI: 1.18-8.28). Symptomatic cases (confirmed by culture) amounted to 3.2% of all children. The carrier rate was 3.8%. Trichophyton tonsurans was the most frequently isolated dermatophyte both in symptomatic children and in carriers. CONCLUSION: In 7% of all children (3.2% with symptoms of tinea capitis, 3.8% without) dermatophytes were cultured from scalp samples, the main aetiologic agent being T. tonsurans.

OBJECTIVE: To establish prevalence and aetiology of tinea capitis in children attending primary school in Amsterdam South-East.DESIGN: Prevalence survey.METHODS: The Municipal Health Service Amsterdam, the Netherlands, selected classes of four primary schools in a survey with children clinically suspected of having tinea capitis as well as classes without clinical cases. Per school at least one class with a notified case was included. Written information was provided to all parents; the parents of three children refused participation. After clinical examination by a team of physicians and nursing staff scalp cultures were taken using the brush method from 315 children (aged 4-12 years) in 16 classes.RESULTS: The clinical diagnosis 'tinea capitis' was established in 25 children, significantly more in boys than in girls (relative risk (RR) = 2.92: 95% confidence interval (95% CI) 1.20-7.11). Of all children 7% had positive cultures, more boys than girls (RR = 3.13: 95% CI: 1.18-8.28). Symptomatic cases (confirmed by culture) amounted to 3.2% of all children. The carrier rate was 3.8%. Trichophyton tonsurans was the most frequently isolated dermatophyte both in symptomatic children and in carriers.CONCLUSION: In 7% of all children (3.2% with symptoms of tinea capitis, 3.8% without) dermatophytes were cultured from scalp samples, the main aetiologic agent being T. tonsurans.

Since 1986 the number of parenteral exposures to potentially infectious blood reported to the Amsterdam Public Health Service increases every year. The number of needlestick accidents increased significantly from 64 in 1986 to 166 in 1996 whereas the number of other exposures decreased from 59 to 44 in these years. The increase was mainly seen in nonhospital based (para)medics. A possible explanation of this increase is greater awareness of the potential infection risk with HIV, hepatitis B or C virus leading to a tendency to report more readily. This assumption is in contradiction with results of studies in hospital-based personnel where a decrease is observed as a result of educational programmes. Other explanations are a higher frequency of use of sharp instruments and (or) an increase in the workload. Out of a total of 1886 needlestick accidents in 1986-1996 one woman became HIV positive; she was deliberately infected by her ex-partner who injected her with blood of an AIDS patient, and one person contracted an hepatitis C virus infection: a policeman wounded by a needle used by a drug addict.

We analyzed the cost-effectiveness of hepatitis A vaccination regimens using a mathematical simulation model. Passive immunization and two active vaccination strategies (with and without prior screening) were compared with "doing nothing." Hepatitis A antibodies were determined in 2,325 Dutch marines; other input data were retrieved from published and unpublished sources. The prevalence of hepatitis A antibody was 14%. Screening before vaccination was identified as appropriate at a prevalence20%. Passive immunization was the cheapest prevention for a single 6-month deployment per 10 years. The inactivated vaccine containing 1,440 enzyme-linked immunosorbent assay units without prior screening was identified as the best option for more frequent deployments. It was cost-saving with two or more missions per 10 years. A 5.3% hepatitis A attack rate validated the investment for this policy. Overall, immunization with inactivated hepatitis A vaccine without prior screening proved to be the optimum strategy for troops at regular risk.

Summary Background Hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B e antigen (anti-HBe) commonly coexist, and laboratory tests are often requested to assess histological hepatitis activity. An optimum panel of tests has not been found and the usefulness of hepatitis B virus (HBV) DNA assays in this context has not been established. We assessed various blood tests to find which best predicted hepatitis activity. Methods Routine plasma biochemical liver tests and serum HBV DNA (hybridisation and PCR assays) were assessed prospectively in 123 patients positive for HBsAg and anti-HBe. We scored histological hepatitis activity (hepatitis activity index) and determined whether chronic active hepatitis (chronic hepatitis with portal and periportal lesions) was present. We analysed the relation between laboratory data and the hepatitis activity index or risk of chronic active hepatitis by multiple regression and multiple logistic regression, respectively. Findings The analyses provided models for predicting either the hepatitis activity index or the risk of chronic active hepatitis. Aspartate aminotransferase was the most important test in the two models. The contribution of HBV DNA and other assays, especially alanine-aminotransferase activity, were of no practical importance. Interpretation Because screening by aspartateaminotransferase activity could not be improved by the addition of other assays or HBV DNA, patients positive for HBsAg and anti-HBe could be screened for chronic active hepatitis with a single assay and counselling of patients can be improved if proper reference values are used.

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We analyzed the cost-effectiveness of hepatitis A vaccination regimens using a mathematical simulation model. Passive immunization and two active vaccination strategies (with and without prior screening) were compared with "doing nothing." Hepatitis A antibodies were determined in 2,325 Dutch marines; other input data were retrieved from published and unpublished sources. The prevalence of hepatitis A antibody was 14%. Screening before vaccination was identified as appropriate at a prevalence > 20%. Passive immunization was the cheapest prevention for a single 6-month deployment per 10 years. The inactivated vaccine containing 1,440 enzyme-linked immunosorbent assay units without prior screening was identified as the best option for more frequent deployments. It was cost-saving with two or more missions per 10 years. A 5.3% hepatitis A attack rate validated the investment for this policy. Overall, immunization with inactivated hepatitis A vaccine without prior screening proved to be the optimum strategy for troops at regular risk.

Limited information existed on the immunogenicity of an inactivated hepatitis A vaccine as part of an extensive vaccination schedule. Dutch marines bound for duty in Cambodia received inactivated hepatitis A vaccine (720 ELISA units of antigen, two intra-gluteal doses at a 2-week interval before departure and an intra-deltoid booster vaccination after 8 months) simultaneously with several other vaccines. Hepatitis A antibodies were determined in blood-samples drawn before and after the booster vaccination, using two laboratory tests (modified HAVAB and SBB-ELISA). At 8 months, before the booster vaccination, 52% (modified HAVAB) and 81% (SBB-ELISA) had seroconverted. Risk factors for non-seroconversion were increasing age and a typhoid vaccination. At 11 months 97.6% (modified HAVAB) and 100% (SBB-ELISA) had seroconverted. Non-seroconversion at 8 months was remarkably high. SBB-ELISA was more sensitive in lower titre ranges.

About 50 of the refugees in Dordrecht are from the Newly Independent States (NIS) of the former USSR, where diphtheria is rife. Cases have arisen in western Europe through contact with cases from the NIS. No NIS-related cases of diphtheria have been seen

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BACKGROUND When in August 1992 it became evident that an outbreak of hepatitis A virus infections (HAV) was taking place in the male homosexual community in Amsterdam a case-control study was conducted to validate the assumption that the outbreak was associated with sexual practices involving oro-anal and digital-anal contact and frequent visits to gay saunas and darkrooms. METHODS In all, 37 cases reported to the Amsterdam Municipal Health Service (AMHS) in the period December 1991 to March 1993 and 68 anti-HAV negative controls completed an anonymous questionnaire concerning the practice of different sexual techniques and the number of visits to gay saunas and darkrooms in the 2 months preceding the onset of illness or date of interview. Controls were recruited from healthy homosexual men participating in a prospective study on HIV/AIDS conducted by the AMHS. RESULTS In univariate analysis a statistically significant association was found between visits to gay saunas and darkrooms, the number of visits to these locations (OR = 8.2) and HAV infection. In the logistic regression analysis the association for visits to saunas and darkrooms remained significant (OR = 10) whereas high-risk sexual techniques could not be included in the model. CONCLUSIONS These results indicate that to prevent future outbreaks of HAV in male homosexuals in Amsterdam there is a need to stress in the 'safe sex' campaigns, directed at the prevention of HIV infection or in additional campaigns, the prevention of other sexually transmitted disease including HAV infection with emphasis on routes associated with certain sexual techniques and on visits to gay saunas and darkrooms.

To evaluate the efficiency of the hepatitis B surface antigen (HBsAg) screening programme in pregnant women and the hepatitis B prevention programme in neonates of HBsAg-positive mothers from October 1989 to December 1991.Retrospective.Amsterdam Public Health Service, the Netherlands.Analysis of the data routinely collected from pregnant women and neonates of these women and calculation of the protective efficiency of this immunisation programme.In 1990, 79% and in 1991, 91% of all pregnant women were screened for HBsAg. The overall prevalence was 1.2% in 1990 as in 1991. Of the HBsAg-positive women 96% originated from countries where hepatitis B virus (HBV) is known to be endemic. At the age of ten months all infants had received passive and active immunisation. The anti-HBs titre was 10-50 IU/l in 8 (7%) infants,50 IU/l in 94 (88%), 3 were HBsAg-negative with no information on the anti-HBs titre and in 2 HBsAg was present. The protective efficiency of the immunisation schedule was 94% in children born of e-antigen-positive and 93% in children born of e-antigen-negative mothers.Active surveillance and intense follow-up are essential in achieving high coverage rates in screening of pregnant women and in immunising neonates of HBsAg-positive mothers.

Titres of antibodies against hepatitis A virus (HAV) were determined in patients, in donors, and in volunteers after active, passive, and combined immunization. Highest titres were found in recently infected persons: in 109 IgM anti-HAV positive persons, the geometric mean titre (GMT) was 15,400 mIU/ml. The GMT in 265 anti-HAV positive blood donors was 10,700 mIU/ml. The anti-HAV seroprevalence in 19,746 donors increases with age: at the age of 40 years, 50% have antibodies. Titres after active, passive, and combined immunization were studied in three groups: 51 persons received inactivated HAV vaccine at months 0, 1, and 6. The GMT after the booster was 3,400 mIU/ml at month 7. All persons produced more than 100 mIU/ml anti-HAV. Forty-nine persons received both 5 ml immunoglobulin and three vaccinations, yielding a GMT of 1,300 mIU/ml at month 7. One person in this group produced less than 100 mIU/ml anti-HAV. Forty-nine persons received 5 ml immunoglobulin intramuscularly. At day 5 the GMT was 96 mIU/ml. The estimated minimum protective level (10 mIU/ml) was reached in 3 months. Hepatitis A vaccination may supersede the use of immunoglobulin as prophylaxis for travellers to endemic areas. Passive immunization remains necessary for protection during outbreaks. The dosage regimen for passive immunization is based on old studies using preparations with unknown anti-HAV content. Concern regarding the antibody levels in immunoglobulin preparations is justified; the prevalence of HAV antibodies in developed countries continues to fall. Our results indicate that dosage regimens should be reconsidered. Dosage should be deduced logically from the anti-HAV antibody content of the immunoglobulin preparation.

The results are reported of AIDS monitoring in Amsterdam in the period 1982-1988. Males with homosexual contacts are the principal risk group followed by the fast-growing group of users of intravenous drugs. Transmission of the human immunodeficiency virus to the heterosexual population will occur mostly via sexual contacts with users of drugs. An investigation of the degree of underreporting in Amsterdam revealed 23 unreported patients (5.7% of the cumulative total). The median duration of survival of AIDS patients increased: 1982-1985, 9 months, 1986, 12 months, 1987, 16 months. Two-year survival of patients in the periods 1986 and 1987 was practically the same, however. It is assumed that at the end of 1991, 1124 AIDS patients domiciled in Amsterdam will have been diagnosed.