Factors potentially contributing to the decline of the mpox outbreak in the Netherlands, 2022 and 2023.

BackgroundIn 2022 and 2023, a global outbreak of mpox affected mostly gay, bisexual and other men having sex with men (GBMSM). Outbreak control in the Netherlands included isolation, quarantine, post-exposure prophylaxis vaccination and primary preventive vaccination (PPV).AimWe describe the course of the outbreak, the vaccination programme, vaccine effectiveness (VE) of full vaccination against symptomatic disease, and trends in behaviour to generate hypotheses about factors that influenced the outbreak's decline.MethodsIn this observational study, we collected data from public health services on notified cases, number of PPV invitations and PPV doses administered. We calculated PPV uptake and coverage. Trends in behavioural data of GBMSM visiting sexual health centres were analysed for all consultations in 2022. We estimated VE using the screening method.ResultsUntil 31 December 2023, 1,294 mpox cases were reported. The outbreak peaked in early July 2022 and then declined sharply. PPV started on 25 July 2022; in total 29,851 doses were administered, 45.8% received at least one dose, 35.4% were fully vaccinated. The estimated VE was 68.2% (95% CI 4.3-89.5%). We did not observe an evident decrease in high-risk behaviour.DiscussionIt is unlikely that PPV was a driver of the outbreak's decline, as incidence started to decline well before the start of the PPV programme. The possible impact of behavioural change could not be demonstrated with the available indicators, however, the data had limitations, hampering interpretation. We hypothesise that infection-induced immunity in high-risk groups was an important factor explaining the decline.

A survey-based assessment of rates and covariates of mpox diagnosis and vaccination provides evidence to refine eligibility criteria for mpox vaccination among gay, bisexual and other men who have sex with men in the Netherlands.

Background: The 2022 multicountry mpox outbreaks predominantly affected gay, bisexual and other men who have sex with men (GBMSM) in non-endemic countries, including in the Netherlands. We conducted a survey-based assessment of the alignment between the risk factors associated with mpox diagnosis among GBMSM in the Netherlands and the eligibility criteria used in 2022 for vaccinating this group, with the aim to refine these criteria. Methods: An online self-report survey was conducted among adult GBMSM in the Netherlands between 29 July and 30 August 2022, corresponding to the first month of the Dutch mpox vaccination campaign. GBMSM were recruited via advertisements on social media and gay dating apps. Participants reported on their sexual behaviour, mpox diagnosis, and/or (initial) mpox vaccination since the start of the outbreak. Covariables of mpox diagnosis and vaccination were assessed using logistic regression analyses. Results: Of the 2,460 participants, 73 (3.0%, 95% CI 2.3-3.6%) were diagnosed with mpox and 485 (19.7%, 95% CI 18.1-21.3%) had received (initial) mpox vaccination. Using sample weighting, we estimated that, of the GBMSM population aged 18-80 years in the Netherlands, 1.1% (95% CI 0.7-1.6%) had been diagnosed with mpox and 7.8% (95% CI 6.8-8.9%) had received (initial) vaccination. HIV-PrEP use, living with HIV, reporting ≥20 sex partners in the past 12 months, and sex in sex venues/parties in the past 2 months were independent risk factors for mpox diagnosis. Except for sex in sex venues/parties, these variables were also independently associated with mpox vaccination. Conclusion: This study provides novel evidence regarding the degree to which the 2022 eligibility criteria for mpox vaccination align with the risk factors for mpox among GBMSM in the Netherlands. The findings contribute to a refinement of the eligibility criteria for mpox vaccination, to which sex in sex venues/parties should be added.

Pediatric acute flaccid myelitis: Evaluation of diagnostic criteria and differentiation from other causes of acute flaccid paralysis.

BACKGROUND: Acute flaccid paralysis (AFP) is characterized by rapidly progressive limb weakness with low muscle tone. It has a broad differential diagnosis, which includes acute flaccid myelitis (AFM), a rare polio-like condition that mainly affects young children. Differentiation between AFM and other causes of AFP may be difficult, particularly at onset of disease. Here, we evaluate the diagnostic criteria for AFM and compare AFM to other causes of acute weakness in children, aiming to identify differentiating clinical and diagnostic features. METHODS: The diagnostic criteria for AFM were applied to a cohort of children with acute onset of limb weakness. An initial classification based on positive diagnostic criteria was compared to the final classification, based on application of features suggestive for an alternative diagnosis and discussion with expert neurologists. Cases classified as definite, probable, or possible AFM or uncertain, were compared to cases with an alternative diagnosis. RESULTS: Of 141 patients, seven out of nine patients initially classified as definite AFM, retained this label after further classification. For probable AFM, this was 3/11, for possible AFM 3/14 and for uncertain 11/43. Patients initially classified as probable or possible AFM were most commonly diagnosed with transverse myelitis (16/25). If the initial classification was uncertain, Guillain-Barré syndrome was the most common diagnosis (31/43). Clinical and diagnostic features not included in the diagnostic criteria, were often used for the final classification. CONCLUSION: The current diagnostic criteria for AFM usually perform well, but additional features are sometimes required to distinguish AFM from other conditions.

Mpox outbreak in the Netherlands, 2022: public health response, characteristics of the first 1,000 cases and protection of the first-generation smallpox vaccine.

In early May 2022, a global outbreak of mpox started among persons without travel history to regions known to be enzootic for monkeypox virus (MPXV). On 8 August 2022, the Netherlands reported its 1,000th mpox case, representing a cumulative incidence of 55 per million population, one of the highest cumulative incidences worldwide. We describe characteristics of the first 1,000 mpox cases in the Netherlands, reported between 20 May and 8 August 2022, within the context of the public health response. These cases were predominantly men who have sex with men aged 31-45 years. The vast majority of infections were acquired through sexual contact with casual partners in private or recreational settings including LGBTQIA+ venues in the Netherlands. This indicates that, although some larger upsurges occurred from point-source and/or travel-related events, the outbreak was mainly characterised by sustained transmission within the Netherlands. In addition, we estimated the protective effect of first-generation smallpox vaccine against moderate/severe mpox and found a vaccine effectiveness of 58% (95% CI: 17-78%), suggesting moderate protection against moderate/severe mpox symptoms on top of any possible protection by this vaccine against MPXV infection and disease. Communication with and supporting the at-risk population in following mitigation measures remains essential.

Wild poliovirus type 3 (WPV3)-shedding event following detection in environmental surveillance of poliovirus essential facilities, the Netherlands, November 2022 to January 2023.

On 21 November 2022, a wild poliovirus type 3 (WPV3) was isolated from an environmental surveillance sample of poliovirus essential facilities in the Netherlands. All 51 employees with access to this strain were screened for ongoing or recent poliovirus infection. One employee shedding WPV3 was identified on 8 December and placed in isolation; monitoring and contact tracing were initiated. WPV3 shedding continued for 4 weeks and stopped 5 January 2023. Isolation was lifted 11 January and no further transmission was detected.

Increase in invasive group A streptococcal (Streptococcus pyogenes) infections (iGAS) in young children in the Netherlands, 2022.

In 2022, a sevenfold increase in the number of notifiable invasive Streptococcus pyogenes (iGAS) infections among children aged 0-5 years was observed in the Netherlands compared with pre-COVID-19 pandemic years. Of 42 cases in this age group, seven had preceding or coinciding varicella zoster infections, nine were fatal. This increase is not attributable to a specific emm type. Vigilance for clinical deterioration as iGAS sign is warranted in young children, especially those with varicella zoster infection.

Epidemiology of acute flaccid myelitis in children in the Netherlands, 2014 to 2019.

BackgroundAcute flaccid myelitis (AFM) is a polio-like condition affecting mainly children and involving the central nervous system (CNS). AFM has been associated with different non-polio-enteroviruses (EVs), in particular EV-D68 and EV-A71. Reliable incidence rates in European countries are not available.AimTo report AFM incidence in children in the Netherlands and its occurrence relative to EV-D68 and EV-A71 detections.MethodsIn 10 Dutch hospitals, we reviewed electronic health records of patients diagnosed with a clinical syndrome including limb weakness and/or CNS infection and who were < 18 years old when symptoms started. After excluding those with a clear alternative diagnosis to AFM, those without weakness, and removing duplicate records, only patients diagnosed in January 2014-December 2019 were retained and further classified according to current diagnostic criteria. Incidence rates were based on definite and probable AFM cases. Cases' occurrences during the study period were co-examined with laboratory-surveillance detections of EV-D68 and EV-A71.ResultsAmong 143 patients included, eight were classified as definite and three as probable AFM. AFM mean incidence rate was 0.06/100,000 children/year (95% CI: -0.03 to 0.14). All patient samples were negative for EV-A71. Of respiratory samples in seven patients, five were EV-D68 positive. AFM cases clustered in periods with increased EV-D68 and EV-A71 detections.ConclusionsAFM is rare in children in the Netherlands. The temporal coincidence of EV-D68 circulation and AFM and the detection of this virus in several cases' samples support its association with AFM. Increased AFM awareness among clinicians, adequate diagnostics and case registration matter to monitor the incidence.

Dynamics in public perceptions and media coverage during an ongoing outbreak of meningococcal W disease in the Netherlands.

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.

Information needs during an emerging outbreak of meningococcal W135 disease in the Netherlands: a study among teenagers, their parents and healthcare professionals.

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.

The role of the media in the amplification of a contested health risk: Rubber granulate on sport fields.

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.

Dynamic Public Perceptions of the Coronavirus Disease Crisis, the Netherlands, 2020.

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.

Out-of-season increase of puerperal fever with group A Streptococcus infection: a case-control study, Netherlands, July to August 2018.

We observed an increase in notifications of puerperal group A Streptococcus (GAS) infections in July and August 2018 throughout the Netherlands without evidence for common sources. General practitioners reported a simultaneous increase in impetigo. We hypothesised that the outbreak of puerperal GAS infections resulted from increased exposure via impetigo in the community.We conducted a case-control study to assess peripartum exposure to possible, non-invasive GAS infections using an online questionnaire. Confirmed cases were recruited through public health services while probable cases and controls were recruited through social media. We calculated odds ratios (OR) and 95% confidence intervals (95% CI) with logistic regression analysis.We enrolled 22 confirmed and 23 probable cases, and 2,400 controls. Contact with persons with impetigo were reported by 8% of cases and 2% of controls (OR: 3.26, 95% CI: 0.98-10.88) and contact with possible GAS infections (impetigo, pharyngitis or scarlet fever) by 28% and 9%, respectively (OR: 4.12, 95% CI: 1.95-8.68). In multivariable analysis, contact with possible GAS infections remained an independent risk factor (aOR: 4.28, 95% CI: 2.02-9.09).We found an increased risk of puerperal fever after community contact with possible non-invasive GAS infections. Further study of this association is warranted.

[The role of children in the transmission of SARS-CoV-2]. / De rol van kinderen in de transmissie van SARS-CoV-2.

OBJECTIVE: To determine whether children play a role in the transmission of SARS-CoV-2 to other children and adults, and to gain insight into symptomatic and asymptomatic infections in children. DESIGN: Analysis of national COVID-19 notifications and prospective observational study in families with children. METHOD: Information about COVID-19 patients and their contacts was obtained from the registration systems used by the public health services. In an ongoing study, patients with COVID-19 were asked to participate if they have a family with children. On two occasions nose-throat swabs and blood were collected for PCR analysis and determination of antibodies against SARS-CoV-2. RESULTS: The notifications suggest that transmission finds place mainly between adults and to a lesser extent between parents and children. For the family study, data were available from 54 households with a total of 227 participants. In families of a confirmed COVID-19 patient, children between 1 and 11 years were less often positive in PCR and serology than older children and adults. CONCLUSION: The study gives no indications that children play an important role in the transmission of SARS-CoV-2. Children can indeed become infected, but transmission mainly takes place between adult peers and from adult family members to children. Transmission among children or from children to adults, as is known in influenza, appears to be less common. Ongoing studies should provide important information for further decision-making on control measures, such as closure of schools.

Meningococcal W135 Disease Vaccination Intent, the Netherlands, 2018-2019.

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.

Public Perceptions of Contentious Risk: The Case of Rubber Granulate in the Netherlands.

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.

Tracing Back the Source of an Outbreak of Salmonella Typhimurium; National Outbreak Linked to the Consumption of Raw and Undercooked Beef Products, the Netherlands, October to December 2015.

INTRODUCTION: On 23 October 2015, six related cases with gastroenteritis called the Netherlands Food and Consumer Product Safety Authority. They suspected filet américain, a raw beef spread, to be the source of infection. Leftovers and stool samples tested positive for Salmonella Typhimurium. Multiple locus variable-number of tandem repeat analysis (MLVA) revealed a MLVA pattern (02-23-08-08-212), which had not been detected in the Netherlands before. Concomitantly, an increase of this MLVA type was observed in the national Salmonella surveillance, amounting to 46 cases between 26 October and 9 December. METHODS: To investigate whether filet américain or an alternative (related) source could  be linked to surveillance-reported cases, cases (n=38) were invited to complete a questionnaire and upstream source tracing to map the food supply chain was initiated. RESULTS: Rapid interdisciplinary action resulted in identification of a contaminated 46-ton batch of beef distributed via a Dutch deboning plant as the likely source of infection. In total, 24/29 respondents (83%) could be linked to the incriminated batch of beef products (predominantly filet américain and minced beef). DISCUSSION: Repeated identification of raw meat products as a source of infection emphasizes the importance of awareness of the risk of infection when handling or consuming these products. Improved measures and procedures on product labelling, pre-treatment or product testing should be considered.

Successful Use of Advertisement Pictures to Assist Recall in a Food-Borne Hepatitis A Outbreak in The Netherlands, 2017.

This study describes an outbreak investigation of 14 hepatitis A cases in the Netherlands. The hepatitis A virus (HAV) genotype IB sequences in cases were highly similar (459/460 nt). The origin of strains could be narrowed to Bulgaria based on information from EPIS-FWD. As an association with consumption of soft fruit was suspected, a case-control study was initiated using a questionnaire and a list of pictures of soft fruit available at the supermarket chain involved. Twelve out of 13 cases consumed a specific frozen raspberry/blueberry product shown on the list (OR 46.0, 95% CI 5.0-27). In multivariable regression analysis this product was the only risk factor (aOR 26.6, 95% CI 2.0-263). Laboratory analyses could not demonstrate HAV-RNA in batches that had been on the market in the incubation period of patients. Trace back of frozen fruit showed that raspberries had been traded by a producer in Bulgaria. After withdrawal of the product from the supermarket no new cases were reported. Use of advertisement pictures of consumed food was helpful in this investigation. Suspicion of the source was strengthened by data from molecular typing and food trace back activities, underlining the importance of good (inter)national cooperation between public health and food safety organisations.

Fatal diphtheria myocarditis in a 3-year-old girl-related to late availability and administration of antitoxin?

Sporadic cases of diphtheria are very rare throughout Europe. A 3-year-old incompletely vaccinated girl was admitted with pharyngotonsillitis caused by diphtheria. On day 9 of her illness, renal and cardiac failure with a third-degree AV-block occurred. Unfortunately, she died within 36 h of admission to intensive care, despite pacemaker placement, the administration of antibiotics and diphtheria antitoxin. The delayed antitoxin administration 7 days after admission to hospital was related to a lack of availability and knowledge of its availability in Europe and this is likely to have contributed to the unfavourable outcome.

Marked increase in leptospirosis infections in humans and dogs in the Netherlands, 2014.

In the Netherlands, 97 human leptospirosis cases were notified in 2014. This represents a 4.6-fold increase in autochthonous cases (n = 60) compared with the annual average between 2010 and 2013. Most cases had symptom onset between June and November. This marked increase in humans coincided with an increase of leptospirosis in dogs. In 2014, 13 dogs with leptospirosis were reported, compared with two to six dogs annually from 2010 to 2013. The majority of the autochthonous cases (n = 20) were linked to recreational exposure, e.g. swimming or fishing, followed by occupational exposure (n = 15). About sixty per cent (n = 37) of the autochthonous cases were most likely attributable to surface water contact, and 13 cases to direct contact with animals, mainly rats. A possible explanation for this increase is the preceding mild winter of 2013-2014 followed by the warmest year in three centuries, possibly enabling rodents and Leptospira spp. to survive better. A slight increase in imported leptospirosis was also observed in Dutch tourists (n = 33) most of whom acquired their infection in Thailand (n = 18). More awareness and early recognition of this mainly rodent-borne zoonosis by medical and veterinary specialists is warranted.