[Influenza vaccination: the Netherlands Health Council missed opportunities]. / De griepprik.

Older adults may suffer from severe sequelae of influenza, including not only respiratory but also cardiovascular complications. Innovative influenza vaccines, such as a high-dose vaccine, offer improved protection for the elderly population. Evidence for the enhanced effectiveness and potential cost savings of these vaccines stems from clinical trials and large observational studies, and several countries already recommend their use. Nonetheless, the Netherlands Health Council, in its recent recommendation, judges that the scientific evidence for added value of these improved vaccines is insufficient. Following the recommendation of the WHO of 2012, the council now does include pregnant women in the target groups for influenza vaccination, primarily to improve indirect protection of newborn children. However, judging that the burden of influenza disease among children is relatively modest, the council does not recommend to include healthy children, despite available evidence for favourable effectiveness and cost-effectiveness of paediatric flu vaccination with a live-attenuated vaccine.

A media intervention applying debunking versus non-debunking content to combat vaccine misinformation in elderly in the Netherlands: A digital randomised trial.

BACKGROUND: As several COVID-19 vaccines are rolled-out globally, it has become important to develop an effective strategy for vaccine acceptance, especially in high-risk groups, such as elderly. Vaccine misconception was declared by WHO as one of the top 10 health issues in 2019. Here we test the effectiveness of applying debunking to combat vaccine misinformation, and reduce vaccine hesitancy. METHODS: Participants were recruited via a daily news show on Dutch Television, targeted to elderly viewers. The study was conducted in 980 elderly citizens during the October 2020 National Influenza Vaccination Campaign. Borrowing from the recent literature in behavioural science and psychology we conducted a two-arm randomized blinded parallel study, in which participants were allocated to exposure to a video containing social norms, vaccine information plus debunking of vaccination myths (intervention group, n = 505) or a video only containing vaccine information plus social norm (control group, n = 475). Participants who viewed either of the video's and completed both a pre- and post-intervention survey on vaccination trust and knowledge, were included in the analysis. The main outcomes of this study were improvement on vaccine knowledge and awareness. FINDINGS: Participants were recruited from the 13th of October 2020 till the 16th of October 2020 and could immediately participate in the pre-intervention survey. Subsequently, eligible participants were randomly assigned to an interventional video and the follow-up survey, distributed through email on the 18th of October 2020, and available for participation till the 24th of October 2020. We found that exposure to the video with addition of debunking strategies on top of social norm modelling and information resulted in substantially stronger rejection of vaccination misconceptions, including the belief that: (1) vaccinations can cause Autism Spectrum Disorders; (2) vaccinations weaken the immune system; (3) influenza vaccination would hamper the COVID-19 vaccine efficacy. Additionally, we observed that exposure to debunking in the intervention resulted in enhanced trust in government. INTERPRETATION: Utilizing debunking in media campaigns on top of vaccine information and social norm modeling is an effective means to combat misinformation and distrust associated with vaccination in elderly, and could help maximize grounds for the acceptance of vaccines, including the COVID-19 vaccines. FUNDING: Dutch Influenza Foundation.

Real-life costs of hepatitis C treatment.

BACKGROUND: Hepatitis C virus infection is a serious health threat in today's society. Improved identification strategies have increased the number of patients undergoing the expensive treatment with ribavirin and peg-interferon, inducing a substantial economic burden. METHODS: In a retrospective cohort study in three treatment centres in the Netherlands, files of patients treated between 2001 and 2010 were systematically searched for all cost-inducing treatment details. Costs of treatment resulting in sustained viral response (SVR), relapse, non-response and the costs per cured patient were specified for genotype and treatment setting. Determinants of costs were determined by multivariate linear regression. RESULTS: The mean 'real-life' treatment costs excluding side effects for genotype 1/4 and genotype 2/3 were approximately € 12,900 and € 9900 for all patients, € 15,500 and € 10,100 for treatment resulting in SVR and € 16,800 and € 12,100 for relapse, respectively. Costs per cured patient were € 28,500 and € 15,400 respectively. The costs of non-response were approximately € 8000 for all genotypes. Costs of side effects can be high and are mainly caused by incidental treatment for neutropenia. Medication is the main component of treatment costs. Treatment costs were higher in the academic setting due to longer duration and higher costs of side effects. Regression analysis confirms duration as the main determinant of treatment costs excluding side effects. CONCLUSION: The 'real-life' costs of treatment are mainly determined by treatment duration, medication costs and costs of side effects. The costs of unsuccessful treatment are considerable as are the costs of side effects. Therefore, future research should aim at increasing SVR rates, reducing treatment duration and preventing side effects.

Cost-effectiveness of targeted screening for hepatitis C in The Netherlands.

On account of the serious complications of hepatitis C virus (HCV) infection and the improved treatment possibilities, the need to improve HCV awareness and case-finding is increasingly recognized. To optimize a future national campaign with this objective, three pilot campaigns were executed in three regions in The Netherlands. One campaign was aimed at the general population, a second (similar) campaign was extended with a support programme for primary care and a third campaign was specifically aimed at hard-drug users. Data from the pilot campaigns were used to build a mathematical model to estimate the incremental cost-effectiveness ratio of the different campaigns. The campaign aimed at the general public without support for primary care did not improve case-finding and was therefore not cost-effective. The similar campaign accompanied by additional support for primary care and the campaign aimed at hard-drug users emerged as cost-effective interventions for identification of HCV carriers.

Effects of a multi-faceted program to increase influenza vaccine uptake among health care workers in nursing homes: A cluster randomised controlled trial.

Despite the recommendation of the Dutch association of nursing home physicians (NVVA) to be immunized against influenza, vaccine uptake among HCWs in nursing homes remains unacceptably low. Therefore we conducted a cluster randomised controlled trial among 33 Dutch nursing homes to assess the effects of a systematically developed multi-faceted intervention program on influenza vaccine uptake among HCWs. The intervention program resulted in a significantly higher, though moderate, influenza vaccine uptake among HCWs in nursing homes. To take full advantage of this measure, either the program should be adjusted and implemented over a longer time period or mandatory influenza vaccination should be considered.

[Influenza vaccination of immunocompromised patients: safe and effective]. / Influenzavaccinatie van patiënten met verminderde afweer: veilig en effectief.

Influenza vaccination is important in order to limit flu-related morbidity and mortality. This especially applies to immunocompromised patients, such as HIV-infected individuals and patients on immunosuppressive treatment, who have an increased risk for developing complications from influenza. Influenza vaccine can be safely administered to all immunocompromised patients, but the effectiveness of the vaccine may be reduced. Uncertainty still exists concerning the value of an increased vaccine dose or booster vaccination: if positive effects exist, they are probably only of marginal clinical importance. Despite clearly reduced effectiveness, vaccination of immunocompromised patients is still valuable in view of the high absolute risk of infection and complications.

Which determinants should be targeted to increase influenza vaccination uptake among health care workers in nursing homes?

Although health care workers (HCWs) have been recommended to be immunized against influenza, vaccine uptake remains low. So far, research on determinants of influenza vaccination among HCWs has been limited by design, population or theoretical framework. Therefore we conducted a questionnaire study in Dutch nursing homes to assess which demographical, behavioural and organisational determinants were associated with influenza vaccine uptake among HCWs. We were able to accurately predict vaccine uptake based on a 13-item prediction model including two demographical, nine behavioural and two organisational determinants developed with data from 1,125 respondents (response rate 60%). To further increase influenza vaccine uptake, implementation programs should target these determinants.

Intervention with educational outreach at large scale to reduce antibiotics for respiratory tract infections: a controlled before and after study.

BACKGROUND: A multiple intervention targeted to reduce antibiotic prescribing with an educational outreach programme had proven to be effective in a randomized controlled trial in 12 peer review groups, demonstrating 12% less prescriptions for respiratory tract infections. OBJECTIVE: To assess the effectiveness of a multiple intervention in primary care at a large scale. METHODS: A controlled before and after study in 2006 and 2007 was designed. Participants were from general practices within a geographically defined area in the middle region of The Netherlands. Participants were GPs in 141 practices in 25 peer review groups. A control group of GP practices from the same region, matched for type of practice and mean volume of antibiotic prescribing. The multiple intervention consisted of the following elements: (i) group education meeting and communication training; (ii) monitoring and feedback on prescribing behaviour; (iii) group education for GPs and pharmacists assistants and (iv) patient education material. The main outcome measures are as follows: (i) number of antibiotic prescriptions per 1000 patients per GP and (ii) number of second-choice antibiotics, obtained from claims data from the regional health insurance company. The associations between predictors and outcome measurements were assessed by means of a multiple regression analyses. RESULTS: At baseline, the number of antibiotic prescriptions per 1000 patients was slightly higher in the intervention group than in the control group (184 versus 176). In 2007, the number of prescriptions had increased to 232 and 227, respectively, and not differed between intervention and control group. CONCLUSIONS: The implementation of an already proven effective multiple intervention strategy at a larger scale showed no reduction of antibiotic prescription rates. The failure might be attributed to a less tight monitoring of intervention and audit. Inserting practical tools in the intervention might be more successful and should be studied.

[Summary of the practice guideline 'Influenza and influenza vaccination' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Influenza en influenzavaccinatie' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The first revision of the guideline 'Influenza and influenza vaccination' from the Dutch College of General Practitioners contains the new indications for influenza vaccination. The most important revisions are: the minimum age has been lowered from 65 to 60 years, the indication for furunculosis patients and their families has been removed, and vaccination is recommended to healthcare professionals who have regular and intensive contact with patients. The purpose of vaccinating healthcare professionals against influenza is to reduce the transmission of the influenza virus to patients at very high risk of complications from influenza and reduce sick leave among healthcare professionals. The use of antiviral agents should only be considered for patients with a very high risk of complications from influenza.

Stagnating influenza vaccine coverage rates among high-risk groups in Poland and Sweden in 2003/4 and 2004/5.

This paper examines influenza vaccine coverage rates (VCR) in Poland and Sweden during the 2003/4 and 2004/5 influenza seasons. An average sample of 2,500 persons was interviewed in each country and each season. Questions regarded age and possible chronic diseases, as well as information on whether they had had an influenza vaccination in the given season. Those who had not received the vaccine were also asked to give reasons for non-vaccination. About one in four (Sweden) to one in three (Poland) of the persons surveyed belonged to high-risk groups (> or = 65 years of age or suffering from chronic diseases). In the 2004/5 season, 17% (CI 12-19%) of the Polish elderly and 45% (CI 39-50%) of the Swedish elderly were vaccinated. In Poland, 9% (CI 7-12%) of respondents younger than 65 years of age with a chronic condition were vaccinated, whereas in Sweden the corresponding rate was 12% (CI 9-16%). In both countries, the VCR did not change significantly from the previous season. Personal invitations resulted in a higher VCR. In Sweden, the most frequently mentioned reasons for not being vaccinated were the assumption of not qualifying for a vaccination and perceived resistance. In Poland in both years, perceived resistance to flu and the cost of the vaccination were the most often mentioned reasons. The influenza vaccination rates in Poland and Sweden remain far below World Health Organization (WHO) recommendations for the high-risk population. No increase in VCR as demonstrated in this study may indicate that these two countries will not be able to meet the 2010 WHO target, if no further action is taken concerning vaccine uptake.

No intention to comply with influenza and pneumococcal vaccination: behavioural determinants among smokers and non-smokers.

OBJECTIVE: Smoking increases the risk for influenza and pneumococcal disease, but vaccination uptake is lower among smokers than non-smokers. We therefore aimed to determine reasons for not complying with vaccination among smokers and non-smokers. METHOD: In 2005 a self-administered questionnaire was sent to a random sample of Dutch patients (n=4,000) assessing medical, social and behavioural determinants. Independent factors associated with not complying with influenza and pneumococcal vaccination among smokers and non-smokers were assessed by multivariate logistic regression analysis. RESULTS: In all, 1,725 of 4,000 patients returned the questionnaire (response rate: 43%), 426 (25%) were smokers. Among smokers self-reported flu vaccine uptake was 42% and among non-smokers 52% among both only 0,2% received both vaccines. Most important predictors of not complying in smokers and non-smokers were patient's beliefs not to be susceptible to disease (odds ratio (OR) 4.0, 95% confidence interval (CI): 2.0, 8.0 and OR 2.8, CI: 2.0, 3.9), finding it difficult to go to the GP for vaccination (OR 2.5, CI: 1.3, 4.8 and OR 1.8, CI: 1.3, 2.6) and being against vaccination (OR 2.4 CI: 1.3, 4.4 and OR 1.8, CI: 1.3, 2.6), respectively. CONCLUSION: There are no substantial differences in determinants associated with not complying with influenza and pneumococcal vaccination between smokers and non-smokers but there is a trend towards stronger associations in smokers.

[The use of antiviral agents during an (impending) influenza pandemic]. / Het gebruik van antivirale middelen tijdens een (dreigende) influenzapandemie.

The preventive and therapeutic principles during an (impending) influenza pandemic differ fundamentally from those prevailing during the annual episodes ofinfluenza. Pending the availability of an effective pandemic vaccine, neuraminidase inhibitors are the only effective agents for the prevention and treatment of infections caused by a pandemic influenza virus. The development of an influenza pandemic has 6 phases: phases 3-5 reflect an increasing threat; phase 6 represents a manifest pandemic. During phases 3-5, a maximum effort is made to prevent or delay a pandemic. Neuraminidase inhibitors should be given not only to patients but also to their close contacts (post-exposure prophylaxis). During phase 6, post-exposure prophylaxis is no longer indicated and neuraminidase inhibitors are prescribed for all patients with symptoms ofpandemic influenza. Prophylaxis without preceding close contact with an influenza patient (primary prophylaxis) is recommended only in exceptional cases. Physicians should not prescribe antiviral drugs on demand to concerned citizens for stockpiling.

[Cheek swelling after surgical removal of third molar]. / Een gezwollen wang na verwijdering van een derde molaar.

A 55-years-old man visited his family doctor because of a one-day existing, not painful, right-sided swelling of the cheek. It appeared to be a subcutaneous emphysema, caused at an attempt to remove mandibular third molar roots, using a water- and air-cooled air rotor. Rare potential seuelae resulting from subcutaneous emphysema are venous air embolism, airway obstruction because of neck swelling, pneumomediastinum, and mediastinitis. Using air-cooled instruments in surgical orofacial treatments should be avoided because of the possible atrogenic life-threatening complications.

[Treatment of patients with herpes zoster by epidural injection of steroids and local anaesthetics: less pain after 1 month, but no effect on long-term postherpetic neuralgia--a randomised trial]. / Behandeling van patiënten met herpes zoster door epidurale injectie van steroïden en lokale anesthetica: minder pijn na 1 maand, maar geen effect op langdurige postherpetische pijn; gerandomiseerd onderzoek.

OBJECTIVE: To assess the effectiveness of a single epidural injection of steroids and local anaesthetics, as a supplement to the standard treatment, for the prevention ofpostherpetic neuralgia in older patients with herpes zoster. DESIGN: Open randomised trial. METHOD: In the period September 2001-February 2004, 598 patients, aged > 50 years, with acute herpes zoster (rash for < 7 days) below dermatome C6, were randomly assigned to receive either standard therapy (oral antiviral agents and analgesics) alone or standard therapy plus an additional single epidural injection of 80 mg methylprednisolone and 10 mg bupivacaine. The primary endpoint was the proportion of patients with zoster-associated pain one month after inclusion. The presence and severity of zoster-associated pain at other time points were secondary endpoints. RESULTS: At one month, pain was reported by 137 (48%) patients in the injection group versus 164 (58%) in the control group (relative risk; RR: 0.83; 95% CI: 0.71-0.97; p = 0.02). After three months, these values were 58 (21%) and 63 (24%), respectively (RR: 0.89; 95% CI: 0.65-1-21; p = 0.47), and at 6 months: 39 (15%) and 44 (17%) (RR: 0.85; 95% CI: 0.57-1-13; p = 0.43). No subgroups were detectable in which the relative risk for pain at one month after inclusion substantially differed from the overall estimate. At one month, the median severity of pain in the injection group was 2 (on a 100-points scale) versus 6 in the control group (p = 0.02). At later follow-up, there was no longer any statistically significant difference in the severity of pain between the two groups. No patient had major adverse events related to the epidural injection. CONCLUSION: A single epidural injection of steroids and local anaesthetics in the acute phase of herpes zoster resulted in a modest decrease in zoster-associated pain in the first month. This treatment did not, however, prevent long-term postherpetic neuralgia.

Negative attitude of highly educated parents and health care workers towards future vaccinations in the Dutch childhood vaccination program.

BACKGROUND: It is unknown whether further expansion of the Dutch childhood vaccination program with other vaccines will be accepted and whom should be targeted in educational strategies. AIM: To determine attitudes of parents towards possible future vaccinations for their children and the behavioural determinants associated with a negative attitude. DESIGN: Questionnaire study. METHODS: Parents of children aged between 3 months and 5 years of day-care centres were asked to fill out a questionnaire. Determinants of a negative attitude to comply with possible future vaccinations against example diseases such as pneumonia or influenza, hepatitis B, TBC, smallpox and SARS were assessed using polytomous logistic regression analysis. RESULTS: Of the 283 respondents, 123 (43%) reported a positive attitude towards all vaccinations, 129 (46%) reported to have a positive attitude to have their child vaccinated against some diseases and 31 (11%) had no intention to comply with any new vaccination. Determinants of a fully negative attitude were a high education of the parent (odds ratio [OR] 3.3, 95% confidence interval [95% CI]: 1.3-8.6), being a health care worker (OR 4.2, 95% CI: 1.4-12.6), absence of religion (OR 2.6, 95% CI: 1.0-6.7), perception of vaccine ineffectiveness (OR 6.9, 95% CI: 2.5-18.9) and the perception that vaccinations cause asthma or allergies (OR 82.4, 95% CI: 8.9-766.8). CONCLUSION: Modifiable determinants for a negative attitude to comply with new vaccinations are mainly based on lack of specific knowledge. These barriers to vaccinations might be overcome by improving health education in the vaccination program, especially when targeted at educated parents and health care workers.

[Practice guideline 'Influenza prevention in nursing homes and care homes', issued by the Dutch Society of Nursing Home Specialists; division of tasks between nursing home specialist, general practitioner and company doctor]. / De richtlijn 'Influenzapreventie in verpleeghuizen en verzorgingshuizen' van de Nederlandse Vereniging van Verpleeghuisartsen; taakverdeling tussen verpleeghuisarts, huisarts en bedrijfsarts.

The Dutch Society of Nursing Home Specialists has formulated a guideline for the prevention of influenza in nursing homes and care homes in The Netherlands. The guideline recommends the realisation of the highest possible degree of vaccination of both patients and health care workers. At the start of the flu season, the manager of the chronic care institute should organize a scheme for vaccination against influenza and a plan in case of an outbreak of influenza. The division of tasks between the nursing home specialist, the general practitioner and the company doctor should be recorded in both the vaccination scheme and the outbreak plan. In order to decrease the incidence of non-response to the vaccine a double dose of influenza vaccine for nursing home patients should be considered. The outbreak plan should raise the state of alertness for influenza and ensure that virological confirmation of clinical influenza is obtained quickly. Immediately after virological confirmation of clinical influenza, patients with influenza should be treated with oseltamivir and both patients and health care workers in the unit should receive prophylaxis with oseltamivir. Non-vaccinated patients should also be offered vaccination to restrict re-introduction of the virus. During an influenza outbreak, only patients with influenza or those who have had prophylactic treatment may be admitted to the facility. In the case of an influenza pandemic, national guidelines should be followed.

Influenza vaccination in Europe: an inventory of strategies to reach target populations and optimise vaccination uptake.

A study was undertaken to assess influenza vaccine uptake in risk groups and to get insight into vaccination practices in European countries. Questionnaires were completed by national influenza experts from 26 countries. Only 14 were able to provide uptake rates for the elderly. For the other risk groups, even fewer could provide data. Vaccines are usually administrated by GPs. Financial incentives for physicians and patients might work as a strategy to increase uptake rates, but due to the small amount of data, it was not possible to carry out thorough multivariate analyses. The development of a uniform influenza vaccination monitoring method was recommended to allow for comparison of uptake data in Europe.

Influenza vaccination in 2000: recommendations and vaccine use in 50 developed and rapidly developing countries.

Influenza vaccination is becoming an increasingly important aspect of public health programs in developed and rapidly developing countries. In 2000, most of these countries had national recommendations to vaccinate elderly people and those with high-risk conditions. Levels of vaccine use, however, varied widely and several rapidly developing countries had higher levels than those seen in many developed countries. More than one-third of all influenza vaccinations occurred in countries outside North America, western Europe and Australia and New Zealand. With increasing vaccine use, all countries will be better prepared for the next pandemic. Nonetheless, those countries that use but do not produce influenza vaccine will find it difficult to obtain supplies of pandemic vaccine.