Perceived utility and feasibility of pathogen genomics for public health practice: a survey among public health professionals working in the field of infectious diseases, Belgium, 2019.

BACKGROUND: Pathogen genomics is increasingly being translated from the research setting into the activities of public health professionals operating at different levels. This survey aims to appraise the literacy level and gather the opinions of public health experts and allied professionals working in the field of infectious diseases in Belgium concerning the implementation of next-generation sequencing (NGS) in public health practice. METHODS: In May 2019, Belgian public health and healthcare professionals were invited to complete an online survey containing eight main topics including background questions, general attitude towards pathogen genomics for public health practice and main concerns, genomic literacy, current and planned NGS activities, place of NGS in diagnostic microbiology pathways, data sharing obstacles, end-user requirements, and key drivers for the implementation of NGS. Descriptive statistics were used to report on the frequency distribution of multiple choice responses whereas thematic analysis was used to analyze free text responses. A multivariable logistic regression model was constructed to identify important predictors for a positive attitude towards the implementation of pathogen genomics in public health practice. RESULTS: 146 out of the 753 invited public health professionals completed the survey. 63% of respondents indicated that public health agencies should be using genomics to understand and control infectious diseases. Having a high level of expertise in the field of pathogen genomics was the strongest predictor of a positive attitude (OR = 4.04, 95% CI = 1.11 - 17.23). A significantly higher proportion of data providers indicated to have followed training in the field of pathogen genomics compared to data end-users (p < 0.001). Overall, 79% of participants expressed interest in receiving further training. Main concerns were related to the cost of sequencing technologies, data sharing, data integration, interdisciplinary working, and bioinformatics expertise. CONCLUSIONS: Belgian health professionals expressed favorable views about implementation of pathogen genomics in their work activities related to infectious disease surveillance and control. They expressed the need for suitable training initiatives to strengthen their competences in the field. Their perception of the utility and feasibility of pathogen genomics for public health purposes will be a key driver for its further implementation.

Incidence rate, predictors and outcomes of interruption of HIV care: nationwide results from the Belgian HIV cohort.

OBJECTIVES: We aimed to study the incidence rate, predictors and outcomes of HIV care interruption (HCI) in Belgium. METHODS: We analysed data for adult patients with at least two HIV care records in the Belgian HIV cohort between 1 January 2007 and 31 December 2016. An HCI episode was defined as 1 year without an HIV care record. The HCI incidence rate was analysed using Poisson regression, return to HIV care using a cumulative incidence function with death as a competing risk, and viral load (VL) status upon return to HIV care using logistic regression. RESULTS: We included 16 066 patients accounting for 78 625 person-years of follow-up. The incidence rate of HCI was 5.3/100 person-years [95% confidence interval (CI) 5.1-5.4/100 person-years]. The incidence of return to HIV care after HCI was estimated at 77.5% (95% CI 75.7-79.2%). Of those who returned to care, 43.7% had a VL ≤ 200 HIV-1 RNA copies/mL, suggesting care abroad or suboptimal care (without an HIV-related care record) in Belgium during the HCI, and 56.3% returned without controlled VL and were therefore considered as having experienced a real gap in HIV care; they represented 2.3/100 person-years of follow-up. Factors individually associated with HCI were no antiretroviral therapy (ART) uptake, lower age, injecting drug use, non-Belgian nationality, male gender, not being a man who has sex with men, a shorter time since HIV diagnosis, no high blood pressure and CD4 count < 350 cells/µL. CONCLUSIONS: This study highlights the need to investigate return to care and viral status at return, to better understand HCI. Identified predictors can help health care workers to target patients at higher risk of HCI for awareness and support.

How can we monitor the impact of national health information systems? Results from a scoping review.

BACKGROUND: National health information (HI) systems provide data on population health, the determinants of health and health system performance within countries. The evaluation of these systems has traditionally focused on statistical practices and procedures, and not on data use or reuse for policy and practice. This limits the capacity to assess the impact of HI systems on healthcare provision, management and policy-making. On the other hand, the field of Knowledge Translation (KT) has developed frameworks to guide evidence into practice. METHODS: A scoping review of the KT literature to identify the essential mechanisms and determinants of KT that could help monitor the impact of HI systems. RESULTS: We examined 79 publications and we identified over 100 different KT frameworks but none of these were focused on HI systems per se. There were specific recommendations on disseminating evidence to stakeholders at the institutional and organizational level, and on sustaining the use of evidence in practice and the broader community setting. CONCLUSIONS: We developed a new model, the HI-Impact framework, in which four domains are essential for mapping the impact of national HI systems: (i) HI Evidence Quality, (ii) HI System Responsiveness, (iii) Stakeholder Engagement and (iv) Knowledge Integration. A comprehensive impact assessment of HI systems requires addressing the use of HI in public health decision-making, health service delivery and in other sectors which might have not been considered previously. Monitoring Stakeholder Engagement and Knowledge Integration certifies that the use of HI in all policies is an explicit point of assessment.

Changes in health in Belgium, 1990-2016: a benchmarking analysis based on the global burden of disease 2016 study.

BACKGROUND: Despite increasing of the Belgian health expenditures, several indicators related to population health showed poor results. The objectives of this study were to perform an in-depth analysis of the secular trend of Belgian health status using the Global Burden of Disease (GBD) 2016 study results for Belgium, and to compare these results with other European countries. METHODS: We collected results of the Global Burden of Disease 2016 study through the GBD results and visualization tools. We benchmarked Belgian GBD results with the other initial members of the European Union (EU15). RESULTS: Belgium performed significantly better in 2016 than in 1990 in terms of age-standardized (AS) Year of Life Lost (YLL) rates but not significantly different in terms of AS Year Lived with Disability (YLD) and Disability-Adjusted Life Year (DALY) rates. The contribution of AS YLDs to total of AS DALYs increased from 1990 (42%) to 2016 (54%). Although AS YLD and DALY rates did not seem to differ between Belgium and the EU15 from 1990 to 2016, the ranking of Belgium among the EU15 in terms of AS DALY and YLL rates was worse in 2016 than in 1990. Belgium had significantly higher AS YLL rates for lower respiratory infections (B: 264 AS YLLs [95% uncertainty interval [UI] 231-301] per 100,000; EU15: 188 AS YLLs [95%UI 168-212] per 100,000), chronic obstructive pulmonary disease (B: 368 AS YLLs [95%UI 331-407] per 100,000; EU15: 285 AS YLLs [95%UI 258-316] per 100,000) and tracheal, bronchus, and lung cancer (B: 785 AS YLLs [95%UI 699-879] per 100,000; EU15: 613 AS YLLs [95%UI 556-674] per 100,000). CONCLUSION: Belgium's ranking among the EU15 in terms of AS YLL and DALY rates decreased from 1990 to 2016. Significant health gains appear possible by acting on risk factors directly linked to a significant part of the Belgian burden of diseases, i.e., alcohol and tobacco consumption, and high body mass index. National burden of disease estimates can help defining Belgian health targets and are necessary as external validity of GBD results is not always guaranteed.

Short-term health effects in the general population following a major train accident with acrylonitrile in Belgium.

BACKGROUND: Following a train derailment, several tons of acrylonitrile (ACN) exploded, inflamed and part of the ACN ended up in the sewage system of the village of Wetteren. More than 2000 residents living in the close vicinity of the accident and along the sewage system were evacuated. A human biomonitoring study of the adduct N-2-cyanoethylvaline (CEV) was carried out days 14-21 after the accident. OBJECTIVES: (1) To describe the short-term health effects that were reported by the evacuated residents following the train accident, and (2) to explore the association between the CEV concentrations, extrapolated at the time of the accident, and the self-reported short-term health effects. METHODS: Short-term health effects were reported in a questionnaire (n=191). An omnibus test of independence was used to investigate the association between the CEV concentrations and the symptoms. Dose-response relationships were quantified by Generalized Additive Models (GAMs). RESULTS: The most frequently reported symptoms were local symptoms of irritation. In non-smokers, dose-dependency was observed between the CEV levels and the self-reporting of irritation (p=0.007) and nausea (p=0.007). Almost all non-smokers with CEV concentrations above 100pmol/g globin reported irritation symptoms. Both absence and presence of symptoms was reported by non-smokers with CEV concentrations below the reference value and up to 10 times the reference value. Residents who visited the emergency services reported more symptoms. This trend was seen for the whole range of CEV concentrations, and thus independently of the dose. DISCUSSION AND CONCLUSION: The present study is one of the first to relate exposure levels to a chemical released during a chemical incident to short-term (self-reported) health effects. A dose-response relation was observed between the CEV concentrations and the reporting of short-term health effects in the non-smokers. Overall, the value of self-reported symptoms to assess exposure showed to be limited. The results of this study confirm that a critical view should be taken when considering self-reported health complaints and that ideally biomarkers are monitored to allow an objective assessment of exposure.

Acrylonitrile exposure in the general population following a major train accident in Belgium: a human biomonitoring study.

BACKGROUND: On Saturday May 4, 2013, a train transporting chemicals derailed in the village of Wetteren (Belgium) and caused a leak of acrylonitrile (ACN). OBJECTIVES: To assess the human exposure to acrylonitrile in the local population with the highest suspected exposure. METHODS: Between May 18-25, 242 residents participated in the study. N-2-cyanoethylvaline (CEV), a biomarker that is highly specific for ACN exposure, was measured in the blood. To account for potential influence by smoking, cotinine was determined in the urine. Participants also filled in a short questionnaire. RESULTS: In the evacuated zone, 37.3% of the non-smokers and 40.0% of the smokers had CEV concentrations above the reference values of 10 and 200 pmol/g globin, respectively, at the time of the train accident. Spatial mapping of the CEV concentrations depending on the residential address showed a distribution pattern following the sewage system. DISCUSSION AND CONCLUSION: The train derailment resulted in a highly atypical sequence-of-events. In addition to exposure in the direct vicinity of the site of the train derailment, exposure also occurred via the sewage system, into which acrylonitrile had entered shortly after the accident.

Acrylonitrile exposure assessment in the emergency responders of a major train accident in Belgium: a human biomonitoring study.

BACKGROUND: On May 4, 2013, a train transporting chemicals derailed in Wetteren, Belgium. Several tanks loaded with acrylonitrile (ACN) exploded, resulting in a fire and a leakage of ACN. OBJECTIVES: To determine exposure to ACN and to assess discriminating factors for ACN exposure in the emergency responders involved in the on-site management of the train accident. METHODS: The study population consisted of 841 emergency responders. Between May 21 and June 28, they gave blood for the determination of N-2-cyanoethylvaline (CEV) hemoglobin adducts and urine for the measurement of cotinine. They also filled in a short questionnaire. RESULTS: 163 (26%) non-smokers and 55 (27%) smokers showed CEV concentrations above the reference values of 10 and 200 pmol/g globin, respectively. The 95th percentile in the non-smokers was 73 pmol/g globin and the maximum was 452 pmol/g globin. ACN exposure among the non-smokers was predicted by (1) the distance to the accident, (2) the duration of exposure, and (3) the occupational function. DISCUSSION AND CONCLUSION: Emergency responders involved in the on-site management of the train accident were clearly exposed to ACN from the accident. However, the extent of exposure remained relatively moderate with CEV concentrations staying within the ranges described in literature as background for a smoking population. Moreover, the exposure was less pronounced in the emergency responders as compared to that in the local population.

Environmental and genomic factors as well as interventions influencing smoking cessation: a systematic review of reviews and a proposed working model.

BACKGROUND: Smoking behaviour is a major public health problem worldwide. Several sources have confirmed the implication of genomic factors in smoking behaviour. These factors interact both with environmental factors and interventions to develop a certain behaviour. OBJECTIVES: Describing the environmental and genomic factors as well as the interventions influencing smoking cessation (SC) and developing a working model incorporating the different factors influencing SC were our main objectives. METHODS: Two systematic reviews were conducted using articles in English from the Cochrane library, PubMed and HuGENet from January 2000 to September 2012: (1) a systematic review of systematic reviews and meta-analyses and (2) a systematic review of original research for genomic factors. The proposed working model was developed by making use of previous models of SC and applying an iterative process of discussion and re-examination by the authors. RESULTS: We confirmed the importance of the 4 main factors influencing SC: (1) environmental factors, (2) genomic factors, (3) gene-environment interactions, and (4) evidence-based interventions. The model demonstrates the complex network of factors influencing SC. CONCLUSION: The working model of SC proposed a global view of factors influencing SC, warranting future research in this area. Future testing of the model will consolidate the understanding of the different factors affecting SC and will help to improve interventions in this field.

Exposure to domoic acid through shellfish consumption in Belgium.

A main known culprit causing amnesic shellfish poisoning in humans is domoic acid (DA). The toxin appearance in sea waters (by counting the toxin producing algae) and consequently in shellfish is closely monitored to prevent acute intoxications with gastrointestinal symptoms and neurological signs. However it is assumed that there might be some chronic problems with repetitive exposures to the toxin in animals. In humans this is greatly unknown and it is mostly assessed by relating reported toxin episodes and representative consumption data. Although in Belgium no alarming outbreaks have been reported in recent years, different concentrations of DA have been found in shellfish samples. In this study the human acute and chronic exposure to DA through shellfish consumption was evaluated by linking the data of DA concentrations in samples collected in the scope of the National Food control program in the period 2004-2009 and consumption data obtained from the National Belgian Food Consumption Survey including 3245 adults. The found level of toxin was highest in scallops while lowest in mussels. The mean usual long-term intake of molluscs such as scallops, mussels and oysters for the whole Belgian population was from 0.10 g/day for scallops to 1.21 g/day for mussels. With average portion size estimated to be 56-108 g/day depending on the shellfish source it was calculated that less than 1% of the population would be at risk of acute intoxication. Using a medium bound approach, 5-6% of the population shows chronic exposure exceeding the tolerable daily intake of 0.075 µg/kg bw per day with scallops being the most probable toxin vector when using lower (68.5%) and medium (45.6%) bound concentrations.

Determinants of folate status in pregnant women: results from a national cross-sectional survey in Belgium.

BACKGROUND/OBJECTIVES: Folic acid deficiency during pregnancy can lead to neural tube defects (NTD) in the fetus. Folate status was determined in a representative sample of Belgian pregnant women and determinants of folate status were assessed. SUBJECTS/METHODS: The women were selected using a multi-stage proportionate-to-size sampling design. Blood samples were collected and a questionnaire was completed face-to-face with a study nurse. Erythrocyte (red blood cell (RBC)) folate concentration was measured by chemoluminescence. RESULTS: In total, 1311 pregnant women participated and women with a lower socio-economic status were well represented. Median RBC folate concentration was 436 ng/ml (95% confidence interval=425-452 ng/ml) among first trimester and 496 ng/ml (95% confidence interval=474-515 ng/ml) among third trimester women. Few women had a RBC folate concentration below 140 ng/ml, indicating depletion of folate stores. In the first trimester, 39% of women had a RBC concentration below 400 ng/ml, whereas 15% of the first trimester women had a RBC concentration below 300 ng/ml. Among women in the first trimester, 69.1% reported taking folic acid-containing supplements of which 41.2% started taking them before pregnancy. For third trimester women, these percentages were 76.2% and 21.9%, respectively. In both trimesters, folate status increased significantly with education level and was significantly higher among women who planned the pregnancy and who did not smoke. CONCLUSIONS: It was found that 39% of the first trimester pregnant women had a folate status that might not be optimal to prevent NTD. Some groups of women need to be targeted as they are at higher risk of inadequate folate status.

Average daily nitrate and nitrite intake in the Belgian population older than 15 years.

The aim of this study was to assess the dietary intake of nitrate and nitrite in Belgium. The nitrate content of processed vegetables, cheeses and meat products was analysed. These data were completed by data from non-targeted official control and from the literature. In addition, the nitrite content of meat products was measured. Concentration data for nitrate and nitrite were linked to food consumption data of the Belgian Food Consumption Survey. This study included 3245 respondents, aged 15 years and older. Food intakes were estimated by a repeated 24-h recall using EPIC-SOFT. Only respondents with two completed 24-h recalls (n=3083) were included in the analysis. For the intake assessment, average concentration data and individual consumption data were combined. Usual intake of nitrate/nitrite was calculated using the Nusser method. The mean usual daily intake of nitrate was 1.38 mg kg(-1) bodyweight (bw) day(-1) and the usual daily intake at the 97.5 percentile was 2.76 mg kg(-1) bw day(-1). Exposure of the Belgian population to nitrate at a mean intake corresponded to 38% of the ADI (while 76% at the 97.5 percentile). For the average consumer, half of the intake was derived from vegetables (especially lettuce) and 20% from water and water-based drinks. The average daily intake of nitrate and nitrite from cheese and meat products was low (0.2% and 6% of the ADI at average intake, respectively). Scenario analyses with a higher consumption of vegetables or a higher nitrate concentration in tap water showed a significant higher intake of nitrate. Whether this is beneficial or harmful must be further assessed.

Optimization of iodine intake in Belgium.

Mild iodine deficiency (MID) is a long-standing problem in Belgium and was recognized only recently as public health issue by the Ministry of Health (MOH). The main MID-related health problems in Belgium are a high prevalence of thyroid nodules and multinodular goiter. The economic cost of thyroid nodular disease only in Belgium was estimated at about €40 millions per year. The Belgian health authorities adopted a selective strategy to optimize iodine intake through the fortification of bread with iodized salt. A progressive, step-by-step increase of the iodine content of salt was chosen in order to minimize the incidence of hyperthyroidism. MOH monitors this strategy by assessing periodically the urinary iodine concentration in school-aged children and pregnant women, as well as by a yearly follow-up of TSH concentrations in all Belgian newborns. Although the implementation of this strategy was an important step, the main drawback of the current situation is the absence of a legal framework to support the strategy. The utilization of iodized salt in bread on a voluntary basis was endorsed by the bakery industry and MOH. However a legal framework is required to assure the effectiveness and continuity of the program and to avoid a higher than optimal iodine intake in the population.

Belgian health-related data in three international databases.

AIMS OF THE STUDY: This study wants to examine the availability of Belgian healthcare data in the three main international health databases: the World Health Organization European Health for All Database (WHO-HFA), the Organisation for Economic Co-operation and Development Health Data 2009 and EUROSTAT. METHODS: For the indicators present in the three databases, the availability of Belgian data and the source of these data were checked. MAIN FINDINGS: The most important problem concerning the availability of Belgian health-related data in the three major international databases is the lack of recent data. Recent data are available for 27% of the indicators of the WHO-HFA database, 73% of the OECD Health Data, and for half of the Eurostat indicators. Especially recent data about health status (including mortality-based indicators) are lacking. DISCUSSION: Only the availability of the health-related data is studied in this article. The quality of the Belgian data is however also important to examine.The main problem concerning the availability of health data is the timeliness. One of the causes of this lack of (especially mortality) data is the reform of the Belgian State. Nowadays mortality data are provided by the communities. This results in a delay in the delivery of national mortality data. However several efforts are made to catch up.

Estimate of total salt intake in two regions of Belgium through analysis of sodium in 24-h urine samples.

OBJECTIVES: To evaluate total salt intake in the adult population through an analysis of sodium in 24-h urine samples in two regions of Belgium. METHODS: Urine samples were collected over 24 h from participants and they had to complete a specific questionnaire about salt intake afterwards. Sodium and creatinine concentrations were analysed in these samples. SUBJECTS: The target population comprised adults aged 45-65 years in the region of Ghent and Liege. A total of 123 and 157 volunteers from Ghent and Liege, respectively, were included in the study. RESULTS: The mean creatinine level in Flanders (n=114) amounted to 0.173±0.035 mmol/kg/day, whereas in the Walloon region (n=135) it amounted to 0.161±0.036 mmol/kg/day, after the exclusion of subjects with incomplete urine collection. Intake of sodium in Flanders (n=114) was 4.29±1.29 g/day, whereas in the Walloon region (n=135) it was 3.94±1.44 g/day. In both regions, sodium intake in men was higher than in women. CONCLUSION: Salt intake was more or less twice as high as the recommended intake. Salt intake as estimated from 24-h urine collections is substantially higher than that previously calculated on the basis of food consumption data. A salt reduction programme for Belgium is primordial.

Energy and macronutrient intakes in Belgium: results from the first National Food Consumption Survey.

Belgium until recently lacked a systematic survey of dietary habits of its inhabitants. The present study evaluated dietary composition in Belgium with respect to energy and macronutrient intakes. Information on food intake was collected using a repeated non-consecutive 24 h recall (2-8 weeks apart) with the validated software package EPIC-SOFT, in combination with a FFQ (self-administered) covering sixty food items. The database of consumed food items was linked to food composition data. Usual macronutrient intake was estimated by the Nusser method. A representative sample of the Belgian population was randomly selected from the national register following a multi-stage procedure. Information on dietary intake was obtained from 3245 subjects aged 15 years and older. Mean energy percentage (E %) of total fat (37.9 E %) and SFA (16.0 E %) was higher than the dietary reference intakes (DRI). Mean E % of total carbohydrates (45.8 E %) was lower than the DRI, while mean E % of mono/disaccharides was 20.3. Total fat and SFA intakes were higher and total carbohydrate and sugar intakes were lower in the older age categories than in the younger age categories. The percentage of energy from SFA intake was lower and that from carbohydrates was higher than that found in an earlier Belgian study. Further efforts are necessary to improve dietary macronutrient intake, taking into account differences in age categories. In addition, it will be important to monitor its changes regularly using trend analyses.

Gender differences in health of EU10 and EU15 populations: the double burden of EU10 men.

This study compares gender differences in Healthy Life Years (HLY) and unhealthy life years (ULY) between the original (EU15) and new member states (EU10). Based on the number of deaths, population and prevalence of activity limitations from the Statistics of Living and Income Conditions Survey (SILC) survey, we calculated HLY and ULY for the EU10 and EU15 in 2006 with the Sullivan method. We used decomposition analysis to assess the contributions of mortality and disability and age to gender differences in HLY and ULY. HLY at age 15 for women in the EU10 were 3.1 years more than those for men at the same age, whereas HLY did not differ by gender in the EU15. In both populations ULY at age 15 for women exceeded those for men by 5.5 years. Decomposition showed that EU10 women had more HLY because higher disability in women only partially offset (-0.8 years) the effect of lower mortality (+3.9 years). In the EU15 women's higher disability prevalence almost completely offset women's lower mortality. The 5.3 fewer ULY in EU10 men than in EU10 women mainly reflected higher male mortality (4.5 years), while the fewer ULY in EU15 men than in EU15 women reflected both higher male mortality (2.9 years) and higher female disability (2.6 years). The absence of a clear gender gap in HLY in the EU15 thus masked important gender differences in mortality and disability. The similar size of the gender gap in ULY in the EU-10 and EU-15 masked the more unfavourable health situation of EU10 men, in particular the much stronger and younger mortality disadvantage in combination with the virtually absent disability advantage below age 65 in men.

Estimate of intake of benzoic acid in the Belgian adult population.

An exposure assessment was performed to estimate average daily benzoic acid intake for Belgian adults. Food consumption data were retrieved from the national food-consumption survey. As a first step, individual food-consumption data were multiplied with the maximum permitted use levels for benzoic acid per food group (Tier 2). As a second step, a label survey to identify the foods where benzoic acid is effectively used as an additive and a literature review of the possible occurrence of benzoic acid as a natural substance were performed. With this information, a refined list of foods was drafted for the quantification of benzoic acid, which was performed by a high-performance liquid chromatography (HPLC) method, optimized and validated for this purpose. Individual food-consumption data were then multiplied with the actual average concentrations of benzoic acid per food group (Tier 3). Usual intakes were calculated using the Nusser method. The mean benzoic acid intake was 1.58 mg kg(-1) body weight day(-1) (Tier 2) and 1.25 mg kg(-1) body weight day(-1) (Tier 3). In Tier 2, men exceeded the acceptable daily intake (ADI) of 5 mg kg(-1) body weight day(-1) at the 99th percentile. The greatest contributors to the benzoic acid intake were soft drinks. Benzoic acid as a natural substance represents only a small percentage of the total intake. The results show that actual benzoic acid intake is very likely to be below the ADI. However, there is a need to collect national food-consumption data for children as they might be more vulnerable to an excessive intake.