Considerable doubt about rubella screening and vaccination among unvaccinated orthodox protestant women: a mixed-methods study.

BACKGROUND: Women who are susceptible to rubella are advised to vaccinate against rubella to prevent infection in future pregnancies, and thus avert the risk of congenital rubella syndrome in their unborn child. Rubella outbreaks periodically occur in the under-vaccinated orthodox Protestant community in the Netherlands. The objective of this mixed-methods study was to determine and understand personal experience with rubella, perceived rubella susceptibility, and intention to accept rubella screening and vaccination among unvaccinated orthodox Protestant women. The ultimate aim of this study was to inform policy and practice and contribute to the prevention of cases of congenital rubella syndrome. METHODS: A mixed-methods study was conducted combining an online survey and semi-structured interviews among unvaccinated Dutch orthodox Protestant women aged 18-40 years. Descriptive analysis was used for quantitative data. Qualitative data was analysed using codes and categories. RESULTS: Results of the survey (167 participants) showed that most participants had personal experience with rubella (74%, 123/167) and 101 women (61%, 101/167) indicated they had had rubella themselves. More than half of the women were undecided whether to accept rubella susceptibility screening (56%; 87/156) or rubella vaccination (55%; 80/146). Qualitative findings (10 participants) showed that most women thought they were not susceptible to rubella. Indecisiveness and negative attitudes to accept rubella vaccination were related with religious arguments to object vaccination and with women's perception of absence of imminent threat of rubella. Furthermore, results showed presence of misconceptions among women in the interpretation of their susceptibility and high confidence in their parents' memory that they had experienced rubella as a child although no laboratory screening had been conducted. CONCLUSIONS: In light of an imminent rubella outbreak in the Netherlands, a tailored education campaign should be prepared aimed at and established in cooperation with the under-vaccinated orthodox Protestant community. Health care providers should provide adequate information on rubella and support decision-making in order to stimulate women to make a deliberate and informed decision on rubella screening and, if necessary, subsequent vaccination.

Contribution of sexual health services to hepatitis B detection and control (Netherlands, 2008-2016).

OBJECTIVES: Case finding is one of the priority actions to reduce the disease burden of chronic hepatitis B (CHB). We estimated the contribution of CHB case finding at sexual health centres (SHCs) to the total national number of newly diagnosed CHB cases in the Netherlands and determined the characteristics of CHB cases detected at SHCs. METHODS: This observational study used surveillance data from all outpatient SHCs in the Netherlands (SOAP database) and the number of CHB from national notification data (Osiris) from 2008 to 2016. The proportion of CHB notifications (hepatitis B surface antigen positive serology) detected at SHCs was calculated. SHC consultations without hepatitis B virus (HBV) testing (n=669 308), with acute hepatitis B diagnosis (n=73), with HBV vaccination only (n=182) or an inconclusive hepatitis B diagnosis (n=24) were excluded. Univariable and multivariable logistic regression analyses were performed, stratified by gender and sexual preference, to analyse patient characteristics associated with CHB. RESULTS: During the study period, 12 149 CHB cases were notified. 405 646 SHC consultations were included in the analysis and 1452 CHB cases (0.4%) were detected at SHCs. The proportion of CHB cases detected at SHCs in relation to the national notified number ranged between 12.4% (200 of 1613) in 2008 and 10.8% (106 of 980) in 2016. 87% of CHB cases were among first-generation migrants (FGMs) originating from high endemic countries for sexually transmitted infections or men who have sex with men (MSM). In multivariable analysis, an older age category, migration background and being a commercial sex worker (CSW) were associated with CHB in all stratified analyses. CONCLUSIONS: The contribution of SHCs is relevant to case finding of CHB in the Netherlands. SHCs should therefore be considered as an important health setting to screen for HBV in high-risk groups, especially among MSM, CSW and FGM, to achieve a reduction in the HBV-related disease burden.

Prevalence of drug use during sex among swingers and perceived benefits and risks - a cross-sectional internet survey in the Netherlands.

OBJECTIVES: Drug use during sex has been associated with sexually transmitted infections (STI). While a growing body of research has investigated drug use during sex among men who have sex with men, data in swingers is limited. Swingers are heterosexual couples who have sex with others and singles who have sex with these couples. Our study assessed the prevalence of drug use during sex and perceived benefits and risks among swingers. METHODS: In 2018, 1005 swingers completed an online questionnaire that was advertised at Dutch swinger-websites. We assessed the associations between drug use during sex <6 months (any drug use excluding alcohol and erection medicines) and sociodemographic characteristics, alcohol use and condomless sex using backward multivariable logistic regression analysis. We compared drug use, motives, beliefs and experienced effects between heterosexual male, bisexual male and female drug-using swingers using χ2-tests. RESULTS: Drug use during sex was reported by 44% (443/1005): 51% in women, 44% in bisexual men and 39% in heterosexual men (P<0.01). Condomless vaginal (46%) and anal sex (22%) was higher in drug-using swingers (vs 34% and 13% in non-drug-using swingers, P<0.001). Among drug-using swingers, XTC (92%), GHB (76%) and laughing gas (69%) were mostly used. Prolonging sex (68%) and increasing arousal (66%) were the most reported motives. Most reported positive effects were feeling happy (78%) and increasing energy (78%). Ninety-four per cent considered drug use to be pleasurable. The most reported negative effect was feeling tired (53%), 7% reported that they might become addicted or felt uncomfortable having sex without drugs. CONCLUSION: This study among a large group of swingers shows that drug use during sex is highly prevalent. STI clinics should discuss drug use during sex among swingers and provide information on safer sex and drug use, while acknowledging the perceived benefits, such as the increased quality of sex.

Objective cognitive performance and subjective complaints in patients with chronic Q fever or Q fever fatigue syndrome.

BACKGROUND: Primary aim of this study was to compare cognitive performance of patients with chronic Q fever or Q fever fatigue syndrome (QFS) to matched controls from the general population, while taking performance validity into account. Second, we investigated whether objective cognitive performance was related to subjective cognitive complaints or psychological wellbeing. METHODS: Cognitive functioning was assessed with a neuropsychological test battery measuring the domains of processing speed, episodic memory, working memory and executive functioning. Tests for performance validity and premorbid intelligence were also included. Validated questionnaires were administered to assess self-reported fatigue, depressive symptoms and cognitive complaints. RESULTS: In total, 30 patients with chronic Q fever, 32 with QFS and 35 controls were included. A high percentage of chronic Q fever patients showed poor performance validity (38%) compared to controls (14%, p = 0.066). After exclusion of participants showing poor performance validity, no significant differences between patients and controls were found in the cognitive domains. QFS patients reported a high level of cognitive complaints compared to controls (41.2 vs 30.4, p = 0.023). Cognitive complaints were not significantly related to cognitive performance in any of the domains for this patient group. CONCLUSIONS: The high level of self-reported cognitive complaints in QFS patients does not indicate cognitive impairment. A large proportion of the chronic Q fever patients showed suboptimal mental effort during neuropsychological assessment. More research into the underlying explanations is needed. Our findings stress the importance of assessing cognitive functioning by neuropsychological examination including performance validity, rather than only measuring subjective cognitive complaints.

Sexually transmitted infections in male heterosexual Dutch clients who visited German cross-border female sex workers; a 3 year retrospective study.

BACKGROUND: Some male heterosexual clients prefer to visit a cross-border Female Sex Worker (FSW) because of cheaper sex and unsafe sex practices, and may therefore be at risk for sexually transmitted infections (STI). The objective of this study was to assess whether having commercial cross-border sex is an independent risk factor for being diagnosed with a STI. METHODS: An observational retrospective study was performed using data of 8 Dutch STI clinics bordering Germany, between 2011 and 2013. All male heterosexual clients of FSWs were selected and data on country of FSW visit and occurrence of STI were used for multivariable regression analysis. RESULTS: The study population consisted of 2664 clients of FSW. Most clients visited the Netherlands (82.4%), followed by visits to another country (beyond cross-border) (9.9%) and cross-border visits (7.8%). Clients of FSW were less likely to be STI positive when they were younger than 25 years(OR = 0.6, 95%CI 0.4 to 0.8 25-44 years and OR = 0.5, 95%CI 0.4 to 0.7 older than 45 years), and more likely when they had 20 or more sex partners in the last 6 months (OR = 2.9, 95%CI 1.9 to 4.4), did not use a condom during last sexual contact (OR = 2.2, 95%CI 1.6 to 2.9) and made cross-border visits (OR = 1.7, 95%CI 1.1 to 2.6). CONCLUSIONS: As cross-border visits appears to be a novel independent risk factor for STI in clients of FSW, this group should therefore be advised on STI prevention.

Incidence, presentation and management of Lyme disease in Dutch general practice.

BACKGROUND: Little is known about the presentation and management of Lyme disease in general practice. OBJECTIVE: To investigate the incidence of Lyme disease over a 6-year period, and its presentation and management in Dutch general practice. METHODS: Observational study using routine data from a practice-based research network in the Netherlands with 7 practices, 24 GPs and 30000 registered patients. From 2009 to 2014, we calculated the incidence of patients presenting with Lyme disease in general practice. We analysed patient characteristics and symptoms that patients presented with at first visit. Furthermore, we analysed General Practitioners' (GPs') diagnostic and therapeutic strategies, and adherence to the national guideline. RESULTS: Over a 6-year period, we found 212 episodes with clinical- or laboratory-based diagnosed Lyme disease, resulting in a mean incidence of 117 cases per 100000 patients per year. We did not identify a significant linear trend over time. The most frequently reported symptoms at first visit were rash (77%) and/or insect bite (58%). In 25% of patients, GPs performed a serological test, in 99% an antibiotic was prescribed and 11% were referred to a medical specialist. Frequently (in 46% of patients), the GP did not adhere to the guideline completely. CONCLUSION: This study shows that there is no linear trend in the incidence of Lyme disease over a 6-year period and that most patients present to GPs with unspecific symptoms like rash or insect bites. We show that GPs frequently (in 46% of patients) do not fully adhere to recommendations stated in the national guideline.

Increase in vaccination coverage between subsequent generations of orthodox Protestants in The Netherlands.

Background: The Netherlands experienced several outbreaks of vaccine preventable diseases, largely confined to an orthodox Protestant minority group. Based on religious arguments some orthodox Protestants accept vaccination, while others refuse. Their acceptance of vaccination, however, seems to be changing over time. We estimated vaccination coverage in subsequent generations of orthodox Protestants and identified determinants of the intention to vaccinate their (future) children. In 2013 orthodox Protestants in the age of 18-40 years were invited to fill out an online questionnaire on their own vaccination status, vaccination status of their parents, the vaccination status or vaccination intention for their (future) children, and possible determinants of the intention to vaccinate (future) children. Vaccination coverage of respondents' parents and respondents was compared using chi-square tests. Logistic regression was used to identify determinants associated with vaccination of (future) children. In total, 981 orthodox Protestant respondents were included in the study. Vaccination coverage among the parents of respondents was 40.1% (95% CI 37.8-42.5%), among respondents 55.3% (95% CI 52.2-58.4%). This means an increase of 15.2% in one generation ( P < 0.001). About 65% of respondents vaccinated or intends to vaccinate their (future) children. Multivariate logistic regression showed that strongest predictors for vaccinating (future) children were low or moderate level of religious conservatism (OR 10.4 [95% CI 5.7-18.9] and 4.6 [95% CI 2.9-7.4], respectively), being vaccinated themselves (OR 6.0 [95% CI 4.3-8.5]) and high educational level (OR 2.5 [95% CI 1.6-4.0]). Vaccination coverage among Dutch orthodox Protestants is increasing over time.

Negative attitude and low intention to vaccinate universally against varicella among public health professionals and parents in the Netherlands: two internet surveys.

BACKGROUND: Prior to introduction of universal varicella vaccination, it is crucial to gain insight into the willingness to vaccinate among the population. This is because suboptimal national vaccination coverage might increase the age of infection in children, which will lead to higher complication rates. We studied the attitude and intention to vaccinate against varicella among Dutch public health professionals who execute the National Immunisation Programme (NIP), and parents. METHODS: Medical doctors and nurses of regional public health services (RPHS) and child health clinics (CHC), and a random sample of parents received an internet survey on varicella vaccination. Separate logistic regression models were used to identify determinants for a positive attitude (professionals) or a positive intention (parents) to vaccinate against varicella within the NIP (free of charge). RESULTS: The questionnaire was completed by 181 RPHS professionals (67%), 260 CHC professionals (46%), and 491 parents (33%). Of professionals, 21% had a positive attitude towards universal varicella vaccination, while 72% preferred to limit vaccination to high-risk groups only. Of parents, 28% had a positive intention to vaccinate their child against varicella within the NIP. The strongest determinant for a positive attitude or intention to vaccinate against varicella among professionals and parents was the belief that varicella is a disease serious enough to vaccinate against. CONCLUSIONS: We showed that a majority of the Dutch public health professionals and parents in this study have a negative attitude or low intention to vaccinate universally against varicella, as a result of the perceived low severity of the disease. Most participating professionals support selective vaccination to prevent varicella among high-risk groups.

Selection of key recommendations for quality indicators describing good quality outbreak response.

BACKGROUND: The performance of recommended control measures is necessary for quick and uniform infectious disease outbreak control. To assess whether these procedures are performed, a valid set of quality indicators (QIs) is required. The goal of this study was to select a set of key recommendations that can be systematically translated into QIs to measure the quality of infectious disease outbreak response from the perspective of disaster emergency responders and infectious disease control professionals. METHODS: Applying the Rand modified Delphi procedure, the following steps were taken to systematically select a set of key recommendations: extraction of recommendations from relevant literature; appraisal of the recommendations in terms of relevance through questionnaires to experts; expert meeting to discuss recommendations; prioritization of recommendations through a second questionnaire; and final expert meeting to approve the selected set. Infectious disease physicians and nurses, policymakers and communication experts participated in the expert group (n=48). RESULTS: In total, 54 national and international publications were systematically searched for recommendations, yielding over 200 recommendations. The Rand modified Delphi procedure resulted in a set of 65 key recommendations. The key recommendations were categorized into 10 domains describing the whole response pathway from outbreak recognition to aftercare. CONCLUSION: This study provides a set of key recommendations that represents 'good quality of response to an infectious disease outbreak'. These key recommendations can be systematically translated into QIs. Organizations and professionals involved in outbreak control can use these QIs to monitor the quality of response to infectious disease outbreaks and to assess in which domains improvement is needed.

Work participation in Q-fever patients and patients with Legionnaires' disease: a 12-month cohort study.

AIMS: The aim of the study was to assess long-term work participation of Q-fever patients and patients with Legionnaires' disease, and to identify which factors are associated with a reduced work participation in Q-fever patients. METHODS: Q-fever patients participated at four time points until 12 months after onset of illness, patients with Legionnaires' disease only at 12 months. Data were self-reported using questionnaires on the amount of hours that patients worked, and on socio-demographic, medical, psychosocial and lifestyle aspects. RESULTS: Our study included 336 Q-fever patients and 190 patients with Legionnaires' disease. There was a decrease in the proportion of Q-fever patients with reduced work participation over time, from 45% at 3 months to 19% at 12 months (versus 15% of patients with Legionnaires' disease at 12 months). Factors associated with reduced work participation of Q-fever patients in a multivariate model were having symptoms, a higher level of sorrow, being a former smoker (compared to never smoking), not consuming any alcohol and following additional treatment for the long-term health effects of Q-fever. CONCLUSIONS: Despite an increase in work participation of Q-fever patients over time, almost one in five Q-fever patients and one in six patients with Legionnaires' disease still suffer from reduced work participation at 12 months. Occupational and insurance physicians need to be aware of the long-term impact of these diseases on work participation.

Determinants of students' willingness to accept a measles-mumps-rubella booster vaccination during a mumps outbreak: a cross-sectional study.

BACKGROUND: Despite high vaccination coverage, a mumps outbreak that affected mainly vaccinated university students and their contacts took place in the Netherlands in the period 2009-2012. We presented university students with a hypothetical case in which we offered them a measles, mumps, and rubella (MMR) booster vaccination to control the mumps outbreak. The aim of this study was to get insight into the determinants of university students' willingness to accept this vaccination. METHODS: A questionnaire containing 38 items was developed for the purpose of assessing students' willingness and the psychosocial and social demographic determinants influencing their willingness to accept an MMR booster vaccination. In addition, we explored how organisational characteristics influenced the willingness to be vaccinated. Data were collected at six Dutch universities; a total of 790 students from various faculties were invited to participate. This was a convenience sampling procedure. RESULTS: 687 university students participated (response rate 87.0%) and 60.4% of the participants said they would be willing accept the hypothetical MMR booster vaccination. The perceived seriousness of mumps (OR 6.1) was the most important predictor of willingness to accept vaccination. Students who expected the MMR vaccination to be effective and to prevent individual illness and who believed their own vaccination would help stop the epidemic were more likely to be willing than others. The students were more willing to accept vaccination when they perceived that the social norms of significant others and the government favoured vaccination. Organisational characteristics, such as offering vaccination cost free and offering it at the university site, increased students' willingness. CONCLUSION: During a mumps outbreak, university students were generally willing to accept a hypothetical MMR booster vaccination. Risk perception, outcome expectations, perceived social norms, and organisational characteristics should be taken into account in the planning of any vaccination campaign for university students during an outbreak of an infectious disease.

Assessing health status and quality of life of Q-fever patients: the Nijmegen Clinical Screening Instrument versus the Short Form 36.

BACKGROUND: The aim of the study was to assess the use of the Nijmegen Clinical Screening Instrument (NCSI) and Short Form 36 (SF-36) in providing a detailed assessment of health status of Q-fever patients and to evaluate which subdomains within the NCSI and SF-36 measure unique aspects of health status. FINDINGS: Patients received a study questionnaire, which contained the NCSI and SF-36. Pearson correlation coefficients between subdomains of the instruments were calculated. The response rate was 94% (309 out of 330 eligible patients). Intercorrelations between subdomains of the NCSI were generally lower than of the SF-36. Four subdomains of the NCSI showed conceptual similarity (Pearson's r ≥ .70) with one or more subdomains of the SF-36 and vice versa. Subdomains that showed no conceptual similarity were NCSI Subjective Pulmonary Symptoms, Subjective Impairment, Dyspnoea Emotions and Satisfaction Relations, and SF-36 Social functioning, Bodily Pain, Role Physical and Role Emotional. CONCLUSIONS: Our results show that either the NCSI or SF-36 can be used to measure health status in Q-fever patients. When the aim is to obtain a detailed overview of the patients' health, a combination of the two instruments, consisting of the complete NCSI and the four unique subdomains of the SF-36, is preferred.

The role of religious leaders in promoting acceptance of vaccination within a minority group: a qualitative study.

BACKGROUND: Although childhood vaccination programs have been very successful, vaccination coverage in minority groups may be considerably lower than in the general population. In order to increase vaccination coverage in such minority groups involvement of faith-based organizations and religious leaders has been advocated. We assessed the role of religious leaders in promoting acceptance or refusal of vaccination within an orthodox Protestant minority group with low vaccination coverage in The Netherlands. METHODS: Semi-structured interviews were conducted with orthodox Protestant religious leaders from various denominations, who were selected via purposeful sampling. Transcripts of the interviews were thematically analyzed, and emerging concepts were assessed for consistency using the constant comparative method from grounded theory. RESULTS: Data saturation was reached after 12 interviews. Three subgroups of religious leaders stood out: those who fully accepted vaccination and did not address the subject, those who had religious objections to vaccination but focused on a deliberate choice, and those who had religious objections to vaccination and preached against vaccination. The various approaches of the religious leaders seemed to be determined by the acceptance of vaccination in their congregation as well as by their personal point of view. All religious leaders emphasized the importance of voluntary vaccination programs and religious exemptions from vaccination requirements. In case of an epidemic of a vaccine preventable disease, they would appreciate a dialogue with the authorities. However, they were not willing to promote vaccination on behalf of authorities. CONCLUSION: Religious leaders' attitudes towards vaccination vary from full acceptance to clear refusal. According to orthodox Protestant church order, local congregation members appoint their religious leaders themselves. Obviously they choose leaders whose views are compatible with the views of the congregation members. Moreover, the positions of orthodox Protestant religious leaders on vaccination will not change easily, as their objections to vaccination are rooted in religious doctrine and they owe their authority to their interpretation and application of this doctrine. Although the dialogue with religious leaders that is pursued by the Dutch government may be helpful in controlling epidemics by other means than vaccination, it is unlikely to increase vaccination coverage.

Assessing the long-term health impact of Q-fever in the Netherlands: a prospective cohort study started in 2007 on the largest documented Q-fever outbreak to date.

BACKGROUND: Between 2007 and 2011, the Netherlands experienced the largest documented Q-fever outbreak to date with a total of 4108 notified acute Q-fever patients. Previous studies have indicated that Q-fever patients may suffer from long-lasting health effects, such as fatigue and reduced quality of life. Our study aims to determine the long-term health impact of Q-fever. It will also compare the health status of Q-fever patients with three reference groups: 1) healthy controls, 2) patients with Legionnaires' disease and 3) persons with a Q-fever infection but a-specific symptoms. METHODS/DESIGN: Two groups of Q-fever patients were included in a prospective cohort study. In the first group the onset of illness was in 2007-2008 and participation was at 12 and 48 months. In the second group the onset of illness was in 2010-2011 and participation was at 6 time intervals, from 3 to 24 months. The reference groups were included at only one time interval. The subjective health status, fatigue status and quality of life of patients will be assessed using two validated quality of life questionnaires. DISCUSSION: This study is the largest prospective cohort study to date that focuses on the effects of acute Q-fever. It will determine the long-term (up to 4 years) health impact of Q-fever on patients and compare this to three different reference groups so that we can present a comprehensive assessment of disease progression over time.

How orthodox protestant parents decide on the vaccination of their children: a qualitative study.

BACKGROUND: Despite high vaccination coverage, there have recently been epidemics of vaccine preventable diseases in the Netherlands, largely confined to an orthodox protestant minority with religious objections to vaccination. The orthodox protestant minority consists of various denominations with either low, intermediate or high vaccination coverage. All orthodox protestant denominations leave the final decision to vaccinate or not up to their individual members. METHODS: To gain insight into how orthodox protestant parents decide on vaccination, what arguments they use, and the consequences of their decisions, we conducted an in-depth interview study of both vaccinating and non-vaccinating orthodox protestant parents selected via purposeful sampling. The interviews were thematically coded by two analysts using the software program Atlas.ti. The initial coding results were reviewed, discussed, and refined by the analysts until consensus was reached. Emerging concepts were assessed for consistency using the constant comparative method from grounded theory. RESULTS: After 27 interviews, data saturation was reached. Based on characteristics of the decision-making process (tradition vs. deliberation) and outcome (vaccinate or not), 4 subgroups of parents could be distinguished: traditionally non-vaccinating parents, deliberately non-vaccinating parents, deliberately vaccinating parents, and traditionally vaccinating parents. Except for the traditionally vaccinating parents, all used predominantly religious arguments to justify their vaccination decisions. Also with the exception of the traditionally vaccinating parents, all reported facing fears that they had made the wrong decision. This fear was most tangible among the deliberately vaccinating parents who thought they might be punished immediately by God for vaccinating their children and interpreted any side effects as a sign to stop vaccinating. CONCLUSIONS: Policy makers and health care professionals should stimulate orthodox protestant parents to make a deliberate vaccination choice but also realize that a deliberate choice does not necessarily mean a choice to vaccinate.

Self-reported sick leave and long-term health symptoms of Q-fever patients.

BACKGROUND: In The Netherlands, 1168 Q-fever patients were notified in 2007 and 2008. Patients and general practitioners (GPs) regularly reported persisting symptoms after acute Q-fever, especially fatigue and long periods of sick leave, to the public health authorities. International studies on smaller Q-fever outbreaks demonstrate that symptoms may persist years after acute illness. Data for the Dutch outbreaks were unavailable. The aim of this study is to quantify sick leave after acute Q-fever and long-term symptoms. METHODS: Our study targeted 898 acute Q-fever patients, notified in 2007 and 2008 residing in the Province Noord-Brabant. Patients from the 2008 cohort were mailed a questionnaire at 12 months and those of the 2007 cohort at 12-26 months after onset of illness. Patients reported underlying illness, Q-fever-related symptoms and sick leave. RESULTS: The response rate was 64%. Forty percent of the working patients reported long-term (>1 month) sick leave. Pre-existent heart disease odds ratio (OR) 4.50; confidence interval (CI) 1.27-16.09), hospitalization in the acute phase (OR 3.99; 95% CI 2.15-7.43) and smoking (OR 1.69; 95% CI 1.01-2.84) were significant predictors for long-term absence. Of the patients who resumed work, 9% were-at the time of completing the questionnaire-still unable to function at pre-infection levels due to fatigue or concentration problems. Of the respondents, 40% reported persisting physical symptoms at the time of follow-up. Fatigue (20%) was most frequently reported. Daily activities were affected in 30% of cases. CONCLUSIONS: Q-fever poses a serious persisting long-term burden on patients and society.

Measuring vaccination coverage in a hard to reach minority.

BACKGROUND: Although childhood vaccination programmes have been very successful, there are some hard to reach minority groups that object to vaccination. The Netherlands has experienced several epidemics of vaccine-preventable diseases, confined to the orthodox Protestant minority. However, vaccination coverage in this minority is still unknown and this hampers prevention and control of epidemics. METHODS: We estimated vaccination coverage among the orthodox Protestant minority and its various subgroups (denominations), using two sub-studies with different design and study population. For both sub-studies separately, we determined overall vaccination coverage and vaccination coverage per denomination. The results were compared and discussed. RESULTS: An online survey was filled out by 1778 orthodox Protestant youngsters, invited via orthodox Protestant media using a snowball method. Next to that, results of a national sample study on vaccination were used, of which only orthodox Protestant respondents were included in our analyses (N = 2129). Overall vaccination coverage among orthodox Protestants in The Netherlands was estimated to be at minimum 60%. Moreover, in both sub-studies three clusters of denominations could be identified, with high (>85%), intermediate (50-75%) and low (<25%) vaccination coverage. CONCLUSION: The integration of both sub-studies, with their own specific strengths and weaknesses, added to our insight in the vaccination coverage in this minority. Based on these results, we recommend to focus prevention and control of vaccine-preventable diseases on the orthodox Protestant subgroups with intermediate and low vaccination coverage.

How healthcare professionals respond to parents with religious objections to vaccination: a qualitative study.

BACKGROUND: In recent years healthcare professionals have faced increasing concerns about the value of childhood vaccination and many find it difficult to deal with parents who object to vaccination. In general, healthcare professionals are advised to listen respectfully to the objections of parents, provide honest information, and attempt to correct any misperceptions regarding vaccination. Religious objections are one of the possible reasons for refusing vaccination. Although religious objections have a long history, little is known about the way healthcare professionals deal with these specific objections. The aim of this study is to gain insight into the responding of healthcare professionals to parents with religious objections to the vaccination of their children. METHODS: A qualitative interview study was conducted with health care professionals (HCPs) in the Netherlands who had ample experience with religious objections to vaccination. Purposeful sampling was applied in order to include HCPs with different professional and religious backgrounds. Data saturation was reached after 22 interviews, with 7 child health clinic doctors, 5 child health clinic nurses and 10 general practitioners. The interviews were thematically analyzed. Two analysts coded, reviewed, discussed, and refined the coding of the transcripts until consensus was reached. Emerging concepts were assessed using the constant comparative method from grounded theory. RESULTS: Three manners of responding to religious objections to vaccination were identified: providing medical information, discussion of the decision-making process, and adoption of an authoritarian stance. All of the HCPs provided the parents with medical information. In addition, some HCPs discussed the decision-making process. They verified how the decision was made and if possible consequences were realized. Sometimes they also discussed religious considerations. Whether the decision-making process was discussed depended on the willingness of the parents to engage in such a discussion and on the religious background, attitudes, and communication skills of the HCPs. Only in cases of tetanus post-exposure-prophylaxis, general practitioners reported adoption of an authoritarian stance. CONCLUSION: Given that the provision of medical information is generally not decisive for parents with religious objections to vaccination, we recommend HCPs to discuss the vaccination decision-making process, rather than to provide them with extra medical information.

Exploring infection prevention practices in home-based nursing care: A qualitative observational study.

BACKGROUND: Home-based nursing care continues to expand, delivering care to increasingly older clients with multiple, chronic and complex conditions that require the use of additional and more numerous invasive medical devices. Therefore, the prevention of infections poses a challenge for nurses, professional caregivers and clients. OBJECTIVE: This article explores infection prevention practices and related behavioural factors in both nurses and clients to identify barriers and facilitators of infection prevention practices in home-based nursing care. DESIGN: A qualitative, exploratory design. SETTING: Four healthcare organisations providing home-based nursing care in the Netherlands. METHODS: Participant observations were used as the main source of data collection complemented with focus group discussions and semi-structured interviews. PARTICIPANTS: Participant observations: 16 nurses, three professional caregivers and 80 clients. Semi-structured interviews: 11 clients. Focus group discussions: 15 nurses and four professional caregivers. RESULTS: A total of 87 unique care delivery situations were observed for 55 h, complemented with three focus group discussions and 11 individual semi-structured client interviews. Infection prevention practices in home-based nursing care appeared to be challenged by 1. The specific context or environment in which the care occurred, which is more autonomous, less structured, less controlled and less predictable than other care settings; 2. Suboptimal and considerable variation in professional performance concerning the application of hand hygiene and the proper use of personal protective equipment such as face masks, barrier gowns and disposable gloves; 3. Extensive use in and outside the client's surroundings of communication devices that are irregularly cleaned and tend to interrupt nursing procedures; and 4. Inadequate organisational support in the implementation and evaluation of new information or policy changes and fragmentation, variation and conflicting information regarding professional guidelines and protocols. CONCLUSIONS: From a first-hand observational viewpoint, this study showed that the daily practice of infection prevention in home-based nursing care appears to be suboptimal. Furthermore, this research revealed considerable variation in the work environment, the application of hand hygiene, the proper use of personal protective equipment, the handling of communication devices and organisational policies, procedures and support. Finally, the study identified a number of important barriers and facilitators of infection prevention practices in the work environment, professional and team performance, clients and organisations.