Determinants of persistent symptoms after treatment for Lyme borreliosis: a prospective observational cohort study.

BACKGROUND: Patients treated for Lyme borreliosis (LB) frequently report persistent symptoms. Little is known about risk factors and etiology. METHODS: In a prospective observational cohort study with a follow-up of one year, we assessed a range of microbiological, immunological, genetic, clinical, functional, epidemiological, psychosocial and cognitive-behavioral variables as determinants of persistent symptoms after treatment for LB. Between 2015 and 2018 we included 1135 physician-confirmed LB patients at initiation of antibiotic therapy, through clinical LB centers and online self-registration. Two reference cohorts of individuals without LB (n = 4000 and n = 2405) served as a control. Prediction analyses and association studies were used to identify determinants, as collected from online questionnaires (three-monthly) and laboratory tests (twice). FINDINGS: Main predictors of persistent symptoms were baseline poorer physical and social functioning, higher depression and anxiety scores, more negative illness perceptions, comorbidity, as well as fatigue, cognitive impairment, and pain in 295 patients with persistent symptoms. The primary prediction model correctly indicated persistent symptoms in 71.0% of predictions (AUC 0.79). In patients with symptoms at baseline, cognitive-behavioral responses to symptoms predicted symptom persistence. Of various microbiological, immunological and genetic factors, only lower IL-10 concentrations in ex vivo stimulation experiments were associated with persistent symptoms. Clinical LB characteristics did not contribute to the prediction of persistent symptoms. INTERPRETATION: Determinants of persistent symptoms after LB were mainly generic, including baseline functioning, symptoms and cognitive-behavioral responses. A potential role of host immune responses remains to be investigated. FUNDING: Netherlands Organisation for Health Research and Development (ZonMw); the Dutch Ministry of Health, Welfare and Sport (VWS).

Corrections to "Prevalence of persistent symptoms after treatment for lyme borreliosis: a prospective observational cohort study" [The Lancet Regional Health - Europe 6 (2021) 100142].

[This corrects the article DOI: 10.1016/j.lanepe.2021.100142.].

First Expert Elicitation of Knowledge on Possible Drivers of Observed Increasing Human Cases of Tick-Borne Encephalitis in Europe.

Tick-borne encephalitis (TBE) is a viral disease endemic in Eurasia. The virus is mainly transmitted to humans via ticks and occasionally via the consumption of unpasteurized milk products. The European Centre for Disease Prevention and Control reported an increase in TBE incidence over the past years in Europe as well as the emergence of the disease in new areas. To better understand this phenomenon, we investigated the drivers of TBE emergence and increase in incidence in humans through an expert knowledge elicitation. We listed 59 possible drivers grouped in eight domains and elicited forty European experts to: (i) allocate a score per driver, (ii) weight this score within each domain, and (iii) weight the different domains and attribute an uncertainty level per domain. An overall weighted score per driver was calculated, and drivers with comparable scores were grouped into three terminal nodes using a regression tree analysis. The drivers with the highest scores were: (i) changes in human behavior/activities; (ii) changes in eating habits or consumer demand; (iii) changes in the landscape; (iv) influence of humidity on the survival and transmission of the pathogen; (v) difficulty to control reservoir(s) and/or vector(s); (vi) influence of temperature on virus survival and transmission; (vii) number of wildlife compartments/groups acting as reservoirs or amplifying hosts; (viii) increase of autochthonous wild mammals; and (ix) number of tick species vectors and their distribution. Our results support researchers in prioritizing studies targeting the most relevant drivers of emergence and increasing TBE incidence.

Lyme neuroborreliosis with antibodies in cerebrospinal fluid but not in serum.

BACKGROUND AND PURPOSE: To diagnose Lyme neuroborreliosis (LNB), cerebrospinal fluid (CSF) is tested for pleocytosis and intrathecal antibody production. The Dutch guideline for Lyme borreliosis indicates a lumbar puncture in the case of positive Borrelia serology or a strong clinical suspicion of LNB. This suggests that LNB might be underdiagnosed in patients with negative Borrelia serology and/or a minor clinical suspicion. The objective was to assess how often negative Borrelia serology occurs in the case of LNB. METHOD: A retrospective study was performed among patients with LNB visiting Gelre Hospitals between January 2007 and December 2020. Electronic medical records of patients with pleocytosis were reviewed to identify patients with LNB. Data were collected from medical records. RESULTS: Included were 127 patients with LNB, 58 of whom were children. In 67 patients Borrelia antibodies were present in both serum and CSF. In 53 of 67 patients there was intrathecal antibody production. In 28 patients there was intrathecal antibody production but serum antibodies were absent. Of patients with positive serology 77% had antibodies in CSF versus 83% of patients with negative serology (p = 0.435). Of patients with positive serology 61% had intrathecal antibody production versus 78% of patients with negative serology (p = 0.073). CONCLUSIONS: Twenty-eight LNB patients had intrathecal antibody production but no antibodies in serum. In this specific patient population, positive serum serology was not associated with antibodies in CSF nor with intrathecal antibody production. In Lyme endemic areas, in patients with symptoms suggestive for LNB, there is a need to lower the threshold for a lumbar puncture.

Coping strategies and quality of life in patients with chronic symptoms visiting a Lyme Center in a Dutch teaching hospital.

INTRODUCTION: Little is known on coping strategies in patients with chronic symptoms suspected of Lyme borreliosis (LB). Different coping strategies might influence quality of life (QoL). We assessed coping strategies and QoL in patients with chronic symptoms suspected of LB. METHODS: Adult patients referred to the Lyme Center Apeldoorn were included (November 2019-April 2021). Participants completed the RAND-36 to assess QoL and the Utrecht Coping List to assess coping strategies. Patient data were extracted from medical records. Patients were categorized based on clinical LB and serology. Linear regression analyses were conducted to examine an association between coping strategies and QoL subscales. RESULTS: Included were 201 patients. Patients suspected of LB had a different coping profile and lower QoL compared to the reference population. Patients with negative serology and no clinical LB scored lowest on all QoL subscales. In multivariate analyses, correcting for age, gender, comorbidity, and patient category, a negative association was found between passive coping and the QoL subscales physical functioning (ß(SE) = - 1.1(0.5)), social functioning (ß(SE) = - 3.3(0.5)), role limitations (emotional) (ß(SE) = - 5.5(0.8)), mental health (ß(SE) = - 3.7(0.3)), vitality (ß(SE) = - 2.3(0.3)), pain (ß(SE) = - 2.3(0.5)), and general health (ß(SE) = - 2.7(0.3)). A negative association was also found between palliative coping and the QoL subscale role limitations (physical) (ß(SE) = - 1.8(0.6)) and between expressing emotions and mental health (ß(SE) = - 1.3(0.6)). A positive association was found between active coping and the QoL subscales mental health (ß(SE) = 1.0(0.3)) and role limitations (emotional) (ß(SE) = 1.9(0.8)). CONCLUSION: In patients suspected of LB, dysfunctional coping strategies were associated with worse quality of life. There is a need for interventions that can guide patients with chronic symptoms suspected of LB towards more active coping and increase QoL.

Identified micro-organisms in hospitalized community-acquired pneumonia patients living near goat and poultry farms.

BACKGROUND: In the Netherlands, an increased risk of community-acquired pneumonia (CAP) has been reported for adults living near goat and poultry farms. Previous results of respiratory microbiome studies in hospitalized CAP patients near poultry farms suggested a higher relative abundance of Streptococcus pneumoniae. This retrospective study, using routine laboratory data from hospitalized CAP patients, aims to explore possible aetiologic micro-organisms of CAP in relation to livestock exposure. METHODS: Patient characteristics and PCR and urinary antigen test results were retrieved retrospectively from electronic medical records of CAP patients admitted to the Jeroen Bosch Hospital or Gelre Hospital in the Netherlands during 2016-2017. Distances between the patients' home address and the nearest poultry and goat farm were calculated. Differences in laboratory test results between CAP patients with and without goat or poultry farms within 2 km of their home address were analyzed using Fisher's exact test. RESULTS: In total, 2230 CAP episodes with diagnostic results were included. In only 25% of the CAP episodes, a micro-organism was detected. A positive urinary antigen test for S. pneumoniae was found more often in patients living within two kilometers of goat (15.2% vs. 11.3%) and poultry farms (14.4% vs. 11.3%), however these differences were not statistically significant (p = 0.1047 and p = 0.1376). CONCLUSION: Our retrospective analysis did not show statistically significant differences in the identified micro-organisms in hospitalized CAP patients related to livestock farming. The study was hampered by limited statistical power and limited laboratory results. Therefore, the potential increased CAP risk around goat and poultry farms will be further explored in a prospective study among CAP patients in primary care.

Prevalence of persistent symptoms after treatment for lyme borreliosis: A prospective observational cohort study.

BACKGROUND: Concerns about long-lasting symptoms attributed to Lyme borreliosis (LB) are widespread in the Western world, while such symptoms are highly prevalent in the general population. METHODS: In the largest prospective study to date, adults with physician-confirmed LB were included at the start of antibiotic treatment. Primary outcomes, prevalence of persistent symptoms and symptom severity, were assessed using three-monthly standardised questionnaires during one year. Persistent symptoms were defined as impaired scores for fatigue (CIS, subscale fatigue), cognitive impairment (CFQ) or pain (SF-36, subscale bodily pain) ≥6 months, with onset <6 months. Outcomes were compared with a longitudinal general population and a tick-bite cohort without LB as a reference. FINDINGS: Of 1135 LB patients (94•8% erythema migrans, 5•2% disseminated LB), 1084 fulfilled primary analysis criteria, as well as 1942 population and 1887 tick-bite controls. Overall prevalence of persistent symptoms in LB patients was 27•2% (95%CI, 24•7%-29•7%); 6•0% and 3•9% higher than in population (21•2%, 95%CI, 19•3%-23•1%; p < 0•0001) and tick-bite (23•3%, 95%CI 21•3%-25•3%; p = 0•016) cohorts, respectively. At 12 months, fatigue, cognitive impairment, and pain were significantly more severe in erythema migrans patients than in reference cohorts, while in disseminated LB patients, only pain was more severe. INTERPRETATION: In treated LB patients, persistent symptoms were significantly more prevalent and symptoms were more severe than in individuals without LB, although the background prevalence was substantial. This suggests an association, either direct or indirect, between persistent symptoms and LB in a relatively small subset of patients. FUNDING: ZonMw; Dutch Ministry of Health, Welfare and Sport.

Nonspecific Symptoms in Children Referred to a Lyme Borreliosis Center.

BACKGROUND: Nonspecific symptoms in children suspected of Lyme borreliosis (LB) are challenging for clinicians. We assessed whether nonspecific symptoms are more prevalent among children with positive immunoglobulin G (IgG) serology or a history of clinical LB. METHODS: We included children (<18 years) suspected of LB who visited the Lyme Center Apeldoorn of Gelre Hospital between 2008 and 2017. Serum samples were taken, and questionnaires on nonspecific symptoms completed. Clinical data were collected from patients' medical records. The prevalence of nonspecific symptoms was compared between patients with positive versus negative IgG serology and between patients with versus without previous LB with the χ and Fisher exact tests with Bonferroni correction. A history of LB was anamnestically determined. Patients with active Lyme manifestations were excluded. RESULTS: Included were 149 children (66% female; median age 13 years); 29 (19%) had positive IgG serology; 36 (24%) had previous LB; 12 (8%) had both. Common nonspecific symptoms were sleep disturbances (58%), severe fatigue (57%) and headache (42%). The prevalence of nonspecific symptoms was similar in children with positive versus negative IgG serology. None of the nonspecific symptoms occurred more frequently in children with previous LB compared with children without. More prevalent in children without previous LB were sleep disturbances (40 vs. 66%; P = 0.002) and tingling (6 vs. 34%; P < 0.001). CONCLUSIONS: Nonspecific symptoms were not more prevalent in children with positive IgG serology nor in children with previous LB, where some were significantly less prevalent. Hence, questionnaires on nonspecific symptoms cannot be used to identify children for serologic testing in Lyme centers.

Prevalence and determinants of persistent symptoms after treatment for Lyme borreliosis: study protocol for an observational, prospective cohort study (LymeProspect).

BACKGROUND: After antibiotic treatment of Lyme borreliosis, a subset of patients report persistent symptoms, also referred to as post-treatment Lyme disease syndrome. The reported prevalence of persistent symptoms varies considerably, and its pathophysiology is under debate. The LymeProspect study has been designed to investigate the prevalence, severity, and a wide range of hypotheses on the etiology of persistent symptoms among patients treated for Lyme borreliosis in the Netherlands. METHODS: LymeProspect is a prospective, observational cohort study among adults with proven or probable Lyme borreliosis, either erythema migrans or disseminated manifestations, included at the start of antibiotic treatment. During one year of follow-up, participants are subjected to questionnaires every three months and blood is collected repeatedly during the first three months. The primary outcome is the prevalence of persistent symptoms after treatment, assessed by questionnaires online focusing on fatigue (CIS, subscale fatigue severity), pain (SF-36, subscale pain) and neurocognitive dysfunction (CFQ). Potential microbiological, immunological, genetic, epidemiological and cognitive-behavioral determinants for persistent symptoms are secondary outcome measures. Control cohorts include patients with long-lasting symptoms and unconfirmed Lyme disease, population controls, and subjects having reported a tick bite not followed by Lyme borreliosis. DISCUSSION: This article describes the background and design of the LymeProspect study protocol. This study is characterized by a prospective, explorative and multifaceted design. The results of this study will provide insights into the prevalence and determinants of persistent symptoms after treatment for Lyme borreliosis, and may provide a rationale for preventive and treatment recommendations. TRIAL REGISTRATION: NTR4998 (Netherlands Trial Register). Date of registration: 13 February 2015.

A summary index for antimicrobial resistance in food animals in the Netherlands.

BACKGROUND: The Dutch government has set targets for reduction of antimicrobial usage in food animals, stipulating a 50% reduction in usage (on a weight basis) in 2013 as compared to 2009 and a 70% decrease in 2015. A monitoring program has been instituted to evaluate the impact on antimicrobial resistance (AMR). The Dutch Ministry of Public Health Welfare and Sports has expressed the need for a summary index to present the results of the monitoring data concisely to policy makers. METHODS: We use data on AMR in bacteria from randomly collected samples from broiler chickens, fattening pigs, veal calves and dairy cows. Escherichia coli was selected for resistance monitoring because they are intrinsically susceptible to the antibiotics included in the test panel (ciprofloxacin, cefotaxime, tetracycline and ampicillin) and they are present in all samples, which facilitates proper randomization and trend analysis. The AMR summary index was calculated for each animal species as a weighted average over the four antibiotics, taking into account their clinical relevance. Weights were obtained by conjoint analysis, a pairwise comparison study involving infectious diseases professionals with clinical and public health backgrounds, with data analysis by conditional logistic regression. The AMR summary index was then computed by Monte Carlo simulation, accounting for sampling and regression uncertainty. RESULTS: The highest weights (0.35) were given to ciprofloxacin and cefotaxime followed by ampicillin (0.23) and tetracycline (0.07). Throughout the years, the AMR index was highest in broiler chickens, followed by pigs and veal calves, while the lowest values were consistently recorded in dairy cows. In all animal species, the index in 2014 was significantly lower than in 2009. CONCLUSIONS: We demonstrate that high-dimensional data on surveillance of antimicrobial resistance can be summarized in an index for evaluating trends between and within food animal species by a process involving decision makers and scientists to select and weight the most relevant antibiotics.

Depressive Symptoms in Patients Referred to a Tertiary Lyme Center: High Prevalence in Those Without Evidence of Lyme Borreliosis.

BACKGROUND: Controversy exists whether mood disorders, such as depression, are associated with Lyme borreliosis (LB). The study objective was to assess prevalence of depressive symptoms in subgroups of patients referred to a tertiary Lyme center, to investigate whether depressive symptoms can be used in clinical practice to discriminate for LB. METHODS: This cohort study included adult patients who visited a tertiary Lyme center between January 2008 and December 2014. Prior to medical consultation, serum samples were taken and the Beck Depression Inventory II was completed to assess depressive symptoms. Lyme diagnosis was retrospectively extracted from the patient's medical record. Patients were classified based on clinical LB and serology results. Prevalence of moderate/severe depressive symptoms was calculated. Using logistic regression, odds ratios with 95% confidence intervals (CIs) were calculated for moderate/severe depressive symptoms. RESULTS: In total, 1454 patients were included. Prevalence of moderate/severe depressive symptoms was lowest in patients with no clinical LB and positive serology (15.3%), higher in patients with clinical LB with positive and negative serology (19.3% and 20.9% respectively), and highest in patients with no clinical LB and negative serology (29.3%). The odds ratio for moderate/severe depressive symptoms in patients with LB and positive serology was 0.71 (95% CI, .50-1.03) compared to patients with no LB and negative serology. CONCLUSIONS: The prevalence of depressive symptoms was similar in patients with LB compared to patients with no evidence of infection. This suggests that depressive symptoms cannot be used to discriminate for LB in a tertiary Lyme center.

Behavioral interventions to reduce HIV risk behavior for MSM and transwomen in Southeast Asia: a systematic review.

This systematic review aims to gain insights from existing literature from Southeast Asian countries to improve future HIV prevention programs for men who have sex with men (MSM) and transgender women (transwomen). We conducted a systematic search in six international databases for literature published prior to 1 January 2015. We included studies describing behavioral interventions targeting MSM and/or transwomen, and conducted in at least one Southeast Asian country. Five out of 575 screened studies met the inclusion criteria and reported a significant intervention effect on at least one outcome measure, that is, condom use (with casual or commercial partner), water-based lubricant use, number of sex partners, HIV prevention knowledge, or willingness to use pre-exposure prophylaxis. Peer education/outreach was the most commonly employed type of intervention in the five included studies and was usually delivered as an element of a larger intervention package, together with condom distribution and the provision of drop-in centers. Motivational interviewing was effective, while internet-based interventions appeared to be a viable platform for intervention delivery. Nevertheless, research on behavioral interventions among MSM and transwomen in Southeast Asia is limited. Future interventions should be culturally appropriate, theoretically grounded, and rigorously evaluated. Only then can we best address the HIV epidemic among MSM and transwomen in this region.

MRSA in persons not living or working on a farm in a livestock-dense area: prevalence and risk factors.

Objectives: MRSA emerged in livestock and persons in contact with livestock is referred to as livestock-associated MRSA (LA-MRSA). We assessed the prevalence and risk factors for MRSA carriage in persons not living or working on a farm. Methods: A cross-sectional study was performed among 2492 adults living in close proximity of livestock farms. Persons working and/or living on farms were excluded. Nasal swabs were cultured using selective media. Participants completed questionnaires and the distance from the residential address to the nearest farm was calculated. The Mann-Whitney U -test was used to compare median distances. Risk factors were explored with logistic regression. Results: Fourteen persons carried MRSA (0.56%; 95% CI 0.32%-0.92%), 10 of which carried LA-MRSA of multiple-locus variable-number tandem repeat analysis complex (MC) 398 (0.40%; 95% CI 0.20%-0.71%). MRSA MC 398 carriers lived significantly closer to the nearest farm than non-carriers (median: 184 versus 402 m; P < 0.01). In bivariate analyses correcting for contact with livestock, this difference remained significant. Conclusions: Although the prevalence was low, living near farms increased the risk of MRSA MC 398 carriage for persons not living or working on a farm. Further research is necessary to identify the transmission routes.

Children's hand hygiene behaviour and available facilities: an observational study in Dutch day care centres.

BACKGROUND: Children attending day care centres are at increased risk of infectious diseases, in particular gastrointestinal and respiratory infections. Hand hygiene of both caregivers and children is an effective prevention measure. This study examined hand hygiene behaviour of children attending day care centres, and describes hygiene facilities at day care centres. METHODS: Data were collected at 115 Dutch day care centres, among 2318 children cared for by 231 caregivers (August to October 2010). Children's hand hygiene behaviour was observed and data on hand hygiene facilities of the day care centres collected by direct unobtrusive observation. National guidelines indicate hand hygiene is required before eating, after toilet use and after playing outside. RESULTS: Among 1930 observed hand hygiene opportunities for children, overall adherence to hand hygiene guidelines was 31% (95% CI: 29-33%). Adherence after both toilet use and playing outside was 48%. Hands were less frequently washed before eating, where guideline adherence was 15%. In 38% of the playrooms there was no soap within reach of children and 17% had no towel facilities. In over 40% of the playrooms, appropriate hand hygiene facilities for children were lacking. CONCLUSION: Adequate hand washing facilities were available for children in only half of the participating day care centres in our study and children washed their hands in only 15-48% of the occasions defined by official guidelines. More attention is needed to hand hygiene of children attending day care centres in the prevention of infectious diseases.

A hand hygiene intervention to decrease infections among children attending day care centers: design of a cluster randomized controlled trial.

BACKGROUND: Day care center attendance has been recognized as a risk factor for acquiring gastrointestinal and respiratory infections, which can be prevented with adequate hand hygiene (HH). Based on previous studies on environmental and sociocognitive determinants of caregivers' compliance with HH guidelines in day care centers (DCCs), an intervention has been developed aiming to improve caregivers' and children's HH compliance and decrease infections among children attending DCCs. The aim of this paper is to describe the design of a cluster randomized controlled trial to evaluate the effectiveness of this intervention. METHODS/DESIGN: The intervention will be evaluated in a two-arm cluster randomized controlled trial among 71 DCCs in the Netherlands. In total, 36 DCCs will receive the intervention consisting of four components: 1) HH products (dispensers and refills for paper towels, soap, alcohol-based hand sanitizer, and hand cream); 2) training to educate about the Dutch national HH guidelines; 3) two team training sessions aimed at goal setting and formulating specific HH improvement activities; and 4) reminders and cues to action (posters/stickers). Intervention DCCs will be compared to 35 control DCCs continuing usual practice. The primary outcome measure will be observed HH compliance of caregivers and children, measured at baseline and one, three, and six months after start of the intervention. The secondary outcome measure will be the incidence of gastrointestinal and respiratory infections in 600 children attending DCCs, monitored over six months by parents using a calendar to mark the days their child has diarrhea and/or a cold. Multilevel logistic regression will be performed to assess the effect of the intervention on HH compliance. Multilevel poisson regression will be performed to assess the incidence of gastrointestinal and respiratory infections in children attending DCCs. DISCUSSION: This is one of the first DCC intervention studies to assess HH compliance of both caregivers and children, as well as the incidence of gastrointestinal and respiratory infections in children, as outcome measures. When an effect of the intervention on improving HH compliance and/or reducing incidence of infections is shown, (inter)national dissemination of the intervention in other DCCs may be considered. TRIAL REGISTRATION: Netherlands trial registry: NTR3000.

Sociocognitive determinants of observed and self-reported compliance to hand hygiene guidelines in child day care centers.

BACKGROUND: Although hand hygiene (HH) has proven to be an effective measure to prevent infections, HH compliance is generally low. We assessed sociocognitive determinants of caregivers' HH behavior in child day care centers (DCCs) to develop an effective HH intervention. METHODS: Caregivers' compliance to HH guidelines was observed. Observed caregivers completed a questionnaire on self-reported HH compliance, sociocognitive determinants, and sociodemographic data. To determine sociocognitive determinants of observed compliance, multilevel logistic regression analyses were performed. Self-reported compliance was analyzed using linear regression. RESULTS: In 122 participating DCCs, 350 caregivers and 2,003 HH opportunities were observed. The response rate on the questionnaire was 100%. Overall observed HH compliance was 42% (841/2,003). Overall mean self-reported HH compliance was 8.7 (scale, 0-10). Guideline knowledge (odds ratio [OR], 1.27; 95% confidence interval [CI]: 1.03-1.56) and perceived disease severity (OR, 0.93; 95% CI: 0.87-0.99) were associated with observed compliance. Guideline knowledge (ß = 0.31; P < .001), guideline awareness (ß = 0.16; P < .001), perceived importance (ß = 0.20; P = .004), perceived behavioral control (ß = 0.24; P < .001), habit (ß = 0.27; P < .001), and children at home (ß = 0.30; P = .002) were associated with self-reported compliance. CONCLUSION: When developing HH interventions for caregivers in DCCs, improving guideline knowledge should be considered as this was associated with both observed and self-reported HH compliance. Furthermore, increasing guideline awareness, perceived importance, and perceived behavioral control can contribute to better HH, as well as making HH a habitual behavior.

Hand hygiene compliance and environmental determinants in child day care centers: an observational study.

BACKGROUND: Children attending day care centers (DCCs) are at high risk for contracting infections, for which hand hygiene (HH) is an effective prevention measure. The study objectives were to assess caregivers' compliance to HH guidelines in DCCs and to identify environmental determinants of HH behavior. METHODS: We observed caregivers' compliance to HH guidelines and collected data on environmental determinants (ie, number of sinks, number and type of towel and soap facilities, availability of alcohol-based hand sanitizers). Using multilevel logistic regression analyses, odds ratios (OR) with 95% confidence intervals (CI) were obtained for environmental determinants of HH behavior. RESULTS: In 122 participating DCCs, 350 caregivers and 2,003 HH opportunities were observed. The overall compliance was 42% (95% CI: 40%-44%). Compliance for different activities for which HH was indicated ranged from 20% to 79%. In the multivariable model, the number of towel facilities per caregiver (OR, 2.33; 95% CI: 1.40-3.88) and type of towel facilities were significantly associated with HH. Hands were most frequently washed when only paper towels were available compared to only fabric towels (OR, 1.47; 95% CI: 1.00-2.16) or a combination of both paper and fabric towels (OR, 2.13; 95% CI: 1.32-3.44). CONCLUSION: HH compliance of caregivers in Dutch child DCCs can be improved. Interventions for this should take into account environmental determinants such as the number and type of towel facilities.