Impact of post-COVID-19 condition on health status and activities of daily living: the PRIME post-COVID study.

OBJECTIVE: To assess health and activities of daily living (ADL) in SARS-CoV-2-positive adults with and without post-COVID-19 condition (PCC) and compare this with negative tested individuals. Furthermore, different PCC case definitions were compared with SARS-CoV-2-negative individuals. METHODS: All adults tested PCR positive for SARS-CoV-2 at the Public Health Service South Limburg (Netherlands) between June 2020 and November 2021 (n=41 780) and matched PCR negative individuals (2:1, on age, sex, year-quarter test, municipality; n=19 875) were invited by email. Health (five-level EuroQol five-dimension (EQ5D) index and EuroQol visual analogue scale (EQVAS)) and ADL impairment were assessed. PCC classification was done using the WHO case definition and five other common definitions. RESULTS: In total, 8409 individuals (6381 SARS-CoV-2 positive; 53±15 years; 57% female; 9 (7-11) months since test) were included. 39.4% of positives had PCC by the WHO case definition (EQVAS: 71±20; EQ5D index: 0.800±0.191; ADL impairment: 30 (10-70)%) and perceived worse health and more ADL impairment than negatives, that is, difference of -8.50 points (95% CI -9.71 to -7.29; p<0.001) for EQVAS, which decreased by 1.49 points (95% CI 0.86 to 2.12; p<0.001) in individuals with PCC for each comorbidity present, and differences of -0.065 points (95% CI -0.074 to -0.056; p<0.001) for EQ5D index, and +16.72% (95% CI 15.01 to 18.43; p<0.001) for ADL impairment. Health and ADL impairment were similar in negatives and positives without PCC. Replacing the WHO case definition with other PCC definitions yielded comparable results. CONCLUSIONS: Individuals with PCC have substantially worse health and more ADL impairment than negative controls, irrespective of the case definition. Authorities should inform the public about the associated burden of PCC and enable adequate support.

Using an Innovative Method for Self-Collection of Capillary Blood for HIV and Syphilis Testing Among Men Who Have Sex With Men Who Use Pre-exposure Prophylaxis in the Netherlands; Limburg4zero.

BACKGROUND: Home-based sampling could create accessible testing opportunities for men who have sex with men (MSM) who use pre-exposure prophylaxis (PrEP). Blood collection is required for the most reliable laboratory results for HIV and syphilis testing. An innovative blood collection method (Tasso+) creates a vacuum and semi-automatically collects larger volumes of blood from the upper arm. This study aimed to assess acceptability and feasibility of this device among PrEP-using MSM and the performance of blood collection. METHODS: Between August 2022 and January 2023, 47 MSM were recruited during their routine PrEP consultations at a Dutch Centre for Sexual Health. Participants tested the method directly after consultation, and an online questionnaire determined acceptability and feasibility. Blood and residual serum volumes were measured after sampling and after HIV and syphilis testing. RESULTS: Of the participants, 87% had a positive attitude toward use of the device, and 77% would use it again for self-sampling at home. Participants rated the use of the blood collection device as easy (96%). On average, 536 µL whole blood (244 µL serum) was collected. All samples were tested for HIV and syphilis, and most samples had sufficient blood for routine HIV (91%) and syphilis testing (89%). Most samples (85%) had 220 µL residual blood, sufficient for further testing (e.g., confirmation). CONCLUSIONS: Blood self-sampling with a method that creates a vacuum from the upper arm is highly acceptable by users and performs well in blood collection for multiple tests. This method has promising potential for use in home-based sexual health care for PrEP-using MSM.

Differences in STI/HIV Burden and Sexual Health Care-Seeking Behavior Among First- and Second-Generation Migrant and Western-Born Male Sex Workers Who Have Sex With Men in the Netherlands: A Retrospective Cohort Study.

BACKGROUND: Globally, migrant sex workers have a higher burden of sexually transmitted infections (STI)/human immunodeficiency virus (HIV). This large study aimed to assess demographics, STI/HIV burden, and sexual health care-seeking behavior of first-generation migrant and second-generation migrant male sex workers who have sex with men (MSW-MSM) versus Western-born MSW-MSM. METHODS: Coded STI clinic consultations (n = 6970) from 3116 individual MSW-MSM attending any Dutch STI clinic between 2016 and 2021 were included. First-generation migrant: born outside of northern/central/southern/western Europe/North America/Oceania. Second-generation migrant: ≥1parent born outside of northern/central/southern/western Europe/North America/Oceania. Multivariable logistic regression analysis assessed associations between MSW-MSM groups and STI in first consultation in the data. A Cox proportional hazard regression compared the incidence of a first repeat consultation between migration groups, stratified by STI in first consultation. All analyses were adjusted for age and urbanity of STI clinic region. RESULTS: First-generation migrant MSW-MSM (n = 1085) were mostly born in Latin America (50%), whereas second-generation migrant MSW-MSM (n = 368) mostly originated from North Africa (30.4%). The proportion of STI diagnoses differed (33.2%, 29.3%, 23.3%; P < 0.001) between the first-generation migrant, second-generation migrant, and Western-born MSW-MSM. First-generation migrant MSW-MSM versus Western-born had an adjusted odds ratio of 1.6 (95% confidence interval, 1.3-1.9) of STI diagnosis in the first consultation. First-generation migrant MSW-MSM versus Western-born had an adjusted hazard ratio of 1.5 (95% confidence interval, 1.3-1.8) of having a first repeat consultation at any time, when stratified for no STI in the first consultation. CONCLUSIONS: The STI/HIV burden is high among all 3 MSW-MSM groups. First-generation migrants have higher odds of STI, but retention in care seems similar. Results highlight the importance of low-threshold STI testing and care for (migrant) MSW-MSM.

Understanding Practical, Robust Implementation and Sustainability of Home-based Comprehensive Sexual Health Care: A Realist Review.

This review identifies which elements of home-based comprehensive sexual health care (home-based CSH) impacted which key populations, under which circumstances. A realist review of studies focused on home-based CSH with at least self-sampling or self-testing HIV and additional sexual health care (e.g., treatment, counseling). Peer-reviewed quantitative and qualitative literature from PubMed, Embase, Cochrane Register of Controlled Trials, and PsycINFO published between February 2012 and February 2023 was examined. The PRISM framework was used to systematically assess the reach of key populations, effectiveness of the intervention, and effects on the adoption, implementation, and maintenance within routine sexual health care. Of 730 uniquely identified records, 93 were selected for extraction. Of these studies, 60% reported actual interventions and 40% described the acceptability and feasibility. Studies were mainly based in Europe or North America and were mostly targeted to MSM (59%; 55/93) (R). Overall, self-sampling or self-testing was highly acceptable across key populations. The effectiveness of most studies was (expected) increased HIV testing. Adoption of the home-based CSH was acceptable for care providers if linkage to care was available, even though a minority of studies reported adoption by care providers and implementation fidelity of the intervention. Most studies suggested maintenance of home-based CSH complementary to clinic-based care. Context and mechanisms were identified which may enhance implementation and maintenance of home-based CSH. When providing the individual with a choice of testing, clear instructions, and tailored dissemination successful uptake of STI and HIV testing may increase. For implementers perceived care and treatment benefits for clients may increase their willingness to implement home-based CSH. Therefore, home-based CSH may determine more accessible sexual health care and increased uptake of STI and HIV testing among key populations.

Perceived barriers and facilitators to infection prevention and control in Dutch residential care facilities for people with intellectual and developmental disabilities: a cross-sectional study.

BACKGROUND: Adequate implementation of infection prevention and control (IPC) in residential care facilities (RCFs) for people with intellectual and developmental disabilities (IDDs) is crucial to safeguarding this vulnerable population. Studies in this field are scarce. This study aimed to identify perceived barriers to and facilitators of IPC among professionals working in these settings, along with recommendations to improve IPC, to inform the development of targeted interventions. METHODS: We administered an online questionnaire to 319 professionals from 16 Dutch RCFs for people with IDDs (March 2021-March 2022). Perceived multilevel barriers and facilitators (guideline, client, interpersonal, organisational, care sector, and policy level) were measured on a 5-point Likert scale (totally disagree-totally agree). Recommendations were assessed using a 5-point Likert scale (not at all helpful-extremely helpful), supplemented by an open-ended question. Barriers, facilitators, and recommendations were analysed by descriptive statistics. Open answers to recommendations were analysed through thematic coding. RESULTS: Barriers to IPC implementation included the client group (e.g., lack of hygiene awareness) (63%), competing values between IPC and the home-like environment (42%), high work pressure (39%), and the overwhelming quantity of IPC guidelines/protocols (33%). Facilitators included perceived social support on IPC between professionals and from supervisors (90% and 80%, respectively), procedural clarity of IPC guidelines/protocols (83%), and the sense of urgency for IPC in the organisation (74%). Main recommendations included the implementation of clear IPC policies and regulations (86%), the development of a practical IPC guideline (84%), and the introduction of structural IPC education and training programmes (for new staff members) (85%). Professionals also emphasised the need for IPC improvement efforts to be tailored to the local care context, and to involve clients and their relatives. CONCLUSIONS: To improve IPC in disability care settings, multifaceted strategies should be adopted. Initial efforts should involve clients (and relatives), develop a practical and context-specific IPC guideline, encourage social support among colleagues through interprofessional coaching, reduce workload, and foster an IPC culture including shared responsibility within the organisation.

Refining Timely Diagnosis of Early Syphilis by Using Treponema pallidum PCR or IgM Immunoblotting Next to Conventional Serology for Syphilis.

Treponema pallidum subsp. pallidum is a fastidious spirochete and the etiologic agent of syphilis, a sexually transmitted infection (STI). Syphilis diagnoses and disease staging are based on clinical findings and serologic testing. Moreover, according to most international guidelines, PCR analysis of swab samples from genital ulcers is included in the screening algorithm where possible. It has been suggested that PCR might be omitted from the screening algorithm due to low added value. As an alternative to PCR, IgM serology might be used. In this study, we wanted to establish the added value of PCR and IgM serology for diagnosing primary syphilis. Added value was defined as finding more cases of syphilis, preventing overtreatment, or limiting the extent of partner notification to more recent partners. We found that both PCR and IgM immunoblotting could aid the timely diagnosis of early syphilis in ~24% to 27% of patients. PCR has the greatest sensitivity and can be applied to cases with an ulcer with suspected reinfection or primary infection. In the absence of lesions, the IgM immunoblot could be used. However, the IgM immunoblot has better performance in cases with suspected primary infection than in reinfections. The target population, testing algorithm, time pressures, and costs should determine whether either test provides sufficient value to be implemented in clinical practice.

Alcohol and drug use during sex and its association with sexually transmitted infections: a retrospective cohort study among young people aged under 25 years visiting Dutch STI clinics.

INTRODUCTION: Alcohol use and drug use are common behaviours among young people. STI positivity is higher in young people than in people aged above 25 years. While there is an increasing amount of knowledge about drug use during sex among men who have sex with men (MSM), data on this behaviour among young women and heterosexual men are scarce. Therefore, this study aims to assess the proportion and characteristics of women and heterosexual men aged under 25 years reporting alcohol and/or drug use during sex and its association with STI positivity. METHODS: Surveillance data of heterosexual individuals younger than 25 years visiting two Dutch STI clinics between 2016 and 2019 were assessed (n=11 714). We used multivariable logistic regression analyses to assess associations between alcohol and drug use during sex and STI positivity (Chlamydia trachomatis and/or Neisseria gonorrhoeae diagnosis), adjusting for sociodemographic characteristics (sex, age, ethnicity, educational level, socioeconomic status and urbanisation) and sexual behaviour (condom use, number of sex partners). RESULTS: Alcohol use during sex was reported by 45.3% (5311/11 714; 49.5% in men vs 43.2% in women, p<0.001) and drug use during sex by 22.0% (2580/11 714; 30.7% in men vs 17.6% in women, p<0.001). The most reported drugs were cannabis (17.9%), ecstasy (XTC)/methylenedioxymethamphetamine (MDMA) (6.9%) and cocaine (4.7%). The use of at least one of the following drugs (XTC/MDMA, cocaine, speed, ketamine, gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL), heroin, crystal meth and/or designer drugs) was significantly associated with STI positivity after adjustment for sociodemographic characteristics (adjusted OR (aOR): 1.3, 95% CI 1.1 to 1.4), but this association did not remain significant after adjustment for sexual behaviour (aOR: 1.12, 95% CI 0.94 to 1.34). Significant associations between drug use during sex and inconsistent condom (aOR: 2.5, 95% CI 1.9 to 3.2) use and having four or more sex partners (aOR: 3.2, 95% CI 2.8 to 3.6) in the past 6 months were assessed. DISCUSSION: Alcohol and drug use during sex was highly prevalent among young women and heterosexual men visiting the STI clinic and drug use during sex was associated with an increased risk for STI, probably mediated by sexual behaviour. This indicates that a holistic health promotion strategy, addressing STI prevention and alcohol and drug use-related harm reduction, is important in this group. STI clinics should address this behaviour not only among MSM, but also among young women and heterosexual men.

Chlamydia trachomatis Coinfection Does Not Influence Mycoplasma genitalium Bacterial Load in Urogenital Samples.

BACKGROUND: Mycoplasma genitalium (MG) is associated with urethritis in men and weakly associated with pelvic inflammatory disease in women. Mycoplasma genitalium coinfections with Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) are commonly reported; however, little is known about their interaction. One study suggested that MG/NG coinfections might increase the bacterial load of NG, which has been shown to have a higher transmission potential. As even less is known about the impact of a simultaneous MG/CT infection, we assessed whether patients with urogenital MG/CT coinfections have a higher bacterial load than patients with a single infection. METHODS: There were 1673 urogenital samples from patients from a population-based chlamydia study, and our sexually transmitted infection clinic tested for both CT and MG. When positive, the load was quantified. Nonparametric tests compared the CT and MG load, and linear regression analyses tested the association of the CT and MG load within a patient. RESULTS: In 60 MG-positive patients, MG load ranged from 1.7 to 6.0 log10 copies/ml, similar to the CT load distribution. Only 6 patients were MG-positive and CT-negative, but the MG load distribution was similar to that of CT-positive patients (n.s.). The MG and CT load was unrelated in coinfected persons (n.s.). CONCLUSIONS: We found no correlation between the CT and MG load in urogenital samples, and the MG load distribution was similar in CT-positive and CT-negative patients. These results could have implications for the transmission risk of these infections.

Sexual (Risk) Behavior and Risk-Reduction Strategies of Home-Based Male Sex Workers Who Have Sex with Men (MSW-MSM) in The Netherlands: A Qualitative Study.

An understanding of sexual (risk) behavior is necessary to successfully develop prevention and care strategies for the sexually transmitted infections (STI) high-risk group of male sex workers who have sex with men (MSW-MSM). However, limited scientific knowledge is available on sexual (risk) behavior of (home-based) MSW-MSM. This study aimed to gain an understanding of sexual (risk) behavior, factors influencing sexual (risk) behavior, and applied risk-reduction strategies of home-based MSW-MSM. For this qualitative study, semi-structured individual interviews were conducted with 20 home-based MSW-MSM in the Netherlands. The interviews' recordings were transcribed verbatim and thematically analyzed with Atlas.ti 8. Condom use was reported to be high during anal sex, but low during oral sex and mostly determined by STI risk perception, trust in clients, and sexual pleasure. Many experienced condom failure, while few knew what to do after condom failure and were aware of post-exposure prophylaxis (PEP). Many MSW-MSM had chemsex in the past 6 months in order to loosen up and enhance sexual pleasure. Some were not vaccinated against hepatitis B virus (HBV), mainly due to the lack of information and awareness of HBV vaccination and low risk perception of HBV. The results of this study can be used to tailor future STI/HIV risk-reduction strategies for home-based MSW-MSM and to increase awareness and uptake of available STI/HIV prevention strategies such as P(r)EP and HBV vaccination.

Psychosocial determinants associated with healthcare workers' self-reported compliance with infection prevention and control during the COVID-19 pandemic: a cross-sectional study in Dutch residential care facilities for people with intellectual and developmental disabilities.

BACKGROUND: Healthcare workers' (HCWs) compliance with infection prevention and control (IPC) is crucial to reduce the infection transmission risk. However, HCWs' compliance with IPC in residential care facilities (RCFs) for people with intellectual and developmental disabilities (IDDs) is known to be suboptimal. Therefore, this study examined sociodemographic and psychosocial determinants associated with IPC non-compliance in this setting, to inform IPC policy and promotion programmes for adequate IPC behaviour. METHODS: An online questionnaire was administered to 285 HCWs from 16 RCFs between March 2021 and March 2022. Determinants associated with IPC non-compliance were assessed using logistic regression analyses. RESULTS: Being a woman (OR: 3.57; 1.73-7.37), and being a non-medical professional were associated with increased odds of non-compliance (social workers, OR: 2.83; 1.65-4.85; behavioural specialists, OR: 6.09; 1.98-18.72). Perceived inadequate education/training (aOR: 1.62; 1.15-2.27) and perceived time constraints/competing priorities (aOR: 1.43; 1.03-1.98) were also associated with increased odds of non-compliance, independent of sociodemographic variables. In contrast, the belief that the supervisor complies with IPC (descriptive norm supervisor) was associated with decreased odds of non-compliance (aOR: 0.60; 0.41-0.88). CONCLUSIONS: To improve IPC in disability care settings, the implementation of tailored and structural IPC education and training programmes (e.g., on-the-job training) is recommended to increase HCWs' capabilities and bridge the IPC compliance gap between medical and non-medical professionals. In addition, role models, particularly supervisors, are crucial for promoting IPC behaviour. Facilities should create a culture of IPC compliance by norm setting, acting on, and modelling IPC behaviours at all levels of the organisation (management, medical, and non-medical staff).

Using a theoretical framework of Intervention Mapping to inform public health communication messages designed to increase vaccination uptake; the example of mpox in the Netherlands.

INTRODUCTION: During an infectious disease outbreak, primary preventive pre-exposure vaccination (PPV) could substantially increase the potential for its control, if uptake is sufficiently high. An important tool to increase PPV uptake, are communication strategies, with tailored messages targeted to modify determinants for PPV uptake. Here, we take the example of the 2022 mpox multicountry outbreak, as we inform the development of communication strategies by applying a theoretical framework for selecting effective communication strategies. METHODS: The theoretical framework Intervention Mapping (IM) was applied during the outbreak to inform communications [program]. Steps included: 1. Creating a logic model of the problem [not accepting PPV] by reviewing available literature, conducting an online survey among people at risk of mpox exposure, and consulting community-members, healthcare-and communication professionals; 2. Creating a matrix of change [from lower to higher PPV acceptance]; and 3. Selecting theory-based methods and practical applications for communication messages to achieve the intended behaviour change (getting vaccinated). RESULTS: The program objective was to promote PPV uptake in people at risk of mpox exposure. Important changeable determinants identified included perceived risk and severity of mpox, importance to protect against mpox [attitude], experienced effectiveness of vaccination and side-effects [response efficacy], and social norm. Theory-based communication methods for optimizing these determinants include provision of facts [increasing knowledge], personalized risk and scenario-based risk information [addressing risk perception/severity], elaboration, arguments [stimulating a positive attitude], gain framing [increasing perceived response efficacy], guided practice [increasing skills/self-efficacy in overcoming barriers] and social norm approach [demonstrating positive norm]. Other key important factors include that communication delivery is uniform (across channels), clear, accessible, and with stigma-free messaging, and that is well-timed and repeated. CONCLUSION: IM provided a valuable tool in selecting communication methods to promote mpox vaccination uptake. These methods can be used to (more quickly) produce and implement a communication program in the context of possible future, vaccine-preventable, infectious disease outbreaks.

Pharyngeal Chlamydia trachomatis in Men Who Have Sex With Men (MSM) in The Netherlands: A Large Retrospective Cohort Study.

Pharyngeal Chlamydia trachomatis (CT) was diagnosed in 1.2% and pharyngeal-only CT in 0.5% of routinely universally tested men who have sex with men (MSM). In these 3-anatomic-site tested MSM, pharyngeal-only CT comprised 4.8% of all CT. The low positivity of pharyngeal-only CT indicates low public health impact of pharyngeal CT.

Incident urogenital and anorectal Chlamydia trachomatis in women: the role of sexual exposure and autoinoculation: a multicentre observational study (FemCure).

BACKGROUND: Anorectal infections with Chlamydia trachomatis (CT) are common in women visiting STI outpatient clinics. We here evaluated the risk posed by sexual exposure and by alternate anatomical site infection for incident anorectal and urogenital CT. METHODS: Prospective multicentre cohort study, FemCure. Participants were treated for CT, and after 4, 6, 8, 10 and 12 weeks, they self-collected anorectal and urogenital samples (swabs) for CT-DNA testing. We calculated the proportion with incident CT, that is, CT incidence (at weeks 6-12) by 2-week time-periods. Compared with no exposure (A), we estimated the risk of incident CT for (B) sexual exposure, (C) alternate site anatomic site infection and (D) both, adjusted for confounders and expressed as adjusted ORs with 95% CIs. RESULTS: We analysed data of 385 participants contributing 1540 2-week periods. The anorectal CT incidence was 2.9% (39/1343) (95 CI 1.8 to 3.6); 1.3% (A), 1.3% (B), 27.8% (C) and 36.7% (D). The ORs were: 0.91 (95% CI 0.32 to 2.60) (B), 26.0 (95% CI 7.16 to 94.34) (C), 44.26 (95% CI 14.38 to 136.21) (D).The urogenital CT incidence was 3.3% (47/1428) (95% CI 2.4 to 4.4); 0.7% (A), 1.9% (B), 13.9% (C) and 25.4% (D). The ORs were: 2.73 (95% CI 0.87 to 8.61) (B), 21.77 (95% CI 6.70 to 70 71) (C) and 49.66 (95% CI 15.37 to 160.41) (D). CONCLUSIONS: After initial treatment, an alternate anatomical site CT infection increased the risk for an incident CT in women, especially when also sex was reported. This may suggest a key role for autoinoculation in the re-establishment or persistence of urogenital and anorectal chlamydia infections.

Who is providing HIV diagnostic testing? Comparing HIV testing by general practitioners and sexual health centres in five regions in the Netherlands, 2011-2018.

OBJECTIVES: General practitioners (GPs) and sexual health centres (SHCs) are the main providers of HIV testing and diagnose two-thirds of HIV infections in the Netherlands. We compared regional HIV testing and positivity by GPs versus SHCs to gain insight into strategies to improve HIV testing, to enable timely detection of HIV infections. METHODS: Laboratory data (2011-2018) on HIV testing by GPs and SHCs in five Dutch regions with varying levels of urbanisation were evaluated. Regional HIV testing rates per 10 000 residents ≥15 years (mean over period and annual) were compared between providers using negative binomial generalised additive models and additionally stratified by sex and age (15-29 years, 30-44 years, 45-59 years, ≥60 years). χ2 tests were used to compare positivity percentage between the two groups of providers. RESULTS: In the study period, 505 167 HIV tests (GP 36%, SHC 64%) were performed. The highest HIV testing rates were observed in highly urbanised regions, with large regional variations. The HIV testing rates ranged from 28 to 178 per 10 000 residents by GPs and from 30 to 378 per 10 000 by SHCs. Testing rates by GPs were lower than by SHCs in three regions and comparable in two. In all regions, men were tested less by GPs than by SHCs; for women, this varied by region. Among those aged 15-29 years old, GPs' testing rates were lower than SHCs', while this was reversed in older age categories in four out of five regions. The overall mean HIV positivity was 0.4%. In contrast to other regions, positivity in Amsterdam was significantly higher among individuals tested by GPs than by SHCs. CONCLUSIONS: This retrospective observational study shows that besides SHCs, who perform opt-out testing for key groups, GPs play a prominent role in HIV testing, especially in non-key populations, such as women and older individuals. Large regional variation exists, requiring region-specific interventions to improve GPs' HIV testing practices.

Determinants associated with viable genital or rectal Chlamydia trachomatis bacterial load (FemCure).

BACKGROUND: Chlamydia trachomatis (CT) is routinely diagnosed by nucleic acid amplification tests (NAATs), which are unable to distinguish between nucleic acids from viable and non-viable CT organisms. OBJECTIVES: We applied our recently developed sensitive PCR (viability PCR) technique to measure viable bacterial CT load and explore associated determinants in 524 women attending Dutch sexual health centres (STI clinics), and who had genital or rectal CT. METHODS: We included women participating in the FemCure study (Netherlands, 2016-2017). At the enrolment visit (pre-treatment), 524 were NAAT positive (n=411 had genital and rectal CT, n=88 had genital CT only and n=25 had rectal CT only). We assessed viable rectal and viable genital load using V-PCR. We presented mean load (range 0 (non-viable) to 6.5 log10 CT/mL) and explored potential associations with urogenital symptoms (coital lower abdominal pain, coital blood loss, intermenstrual bleeding, altered vaginal discharge, painful or frequent micturition), rectal symptoms (discharge, pain, blood loss), other anatomical site infection and sociodemographics using multivariable regression analyses. RESULTS: In genital (n=499) CT NAAT-positive women, the mean viable load was 3.5 log10 CT/mL (SD 1.6). Genital viable load was independently associated with urogenital symptoms-especially altered vaginal discharge (Beta=0.35, p=0.012) and with concurrent rectal CT (aBeta=1.79; p<0.001). Urogenital symptoms were reported by 50.3% of women; their mean genital viable load was 3.6 log10 CT/mL (vs 3.3 in women without symptoms). Of 436 rectal CT NAAT-positive women, the mean rectal viable load was 2.2 log10 CT/mL (SD 2.0); rectal symptoms were reported by 2.5% (n=11) and not associated with rectal viable load. CONCLUSION: Among women diagnosed with CT in an outpatient clinical setting, viable genital CT load was higher in those reporting urogenital symptoms, but the difference was small. Viable genital load was substantially higher when women also had a concurrent rectal CT. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02694497.

Barriers and facilitators to infection prevention and control in Dutch psychiatric institutions: a theory-informed qualitative study.

BACKGROUND: The unique characteristics of psychiatric institutions contribute to the onset and spread of infectious agents. Infection prevention and control (IPC) is essential to minimise transmission and manage outbreaks effectively. Despite abundant studies regarding IPC conducted in hospitals, to date only a few studies focused on mental health care settings. However, the general low compliance to IPC in psychiatric institutions is recognised as a serious concern. Therefore, this study aimed to assess perceived barriers and facilitators to IPC among professionals working at psychiatric institutions, and to identify recommendations reported by professionals to improve IPC. METHODS: A descriptive, qualitative study involving 16 semi-structured interviews was conducted (before COVID-19) among professionals from five Dutch psychiatric institutions. The interview guide and data analysis were informed by implementation science theories, and explored guideline, individual, interpersonal, organisational, and broader environment barriers and facilitators to IPC. Data was subjected to thematic analysis, using inductive and deductive approaches. This study followed the Consolidated criteria for Reporting Qualitative research (COREQ) guidelines. RESULTS: Our findings generated six main themes: (1) patients' non-compliance (strongly related to mental illness); (2) professionals' negative cognitions and attitude towards IPC and IPC knowledge deficits; (3) monitoring of IPC performance and mutual professional feedback; (4) social support from professional to patient; (5) organisational support and priority; and (6) financial and material resource limitations (related to financial arrangements regarding mental health services). The main recommendations reported by professionals included: (1) to increase awareness towards IPC among all staff members, by education and training, and the communication of formal agreements as institutional IPC protocols; (2) to make room for and facilitate IPC at the organisational level, by providing adequate IPC equipment and appointing a professional responsible for IPC. CONCLUSIONS: IPC implementation in psychiatric institutions is strongly influenced by factors on the patient, professional and organisational level. Professional interaction and professional-patient interaction appeared to be additional important aspects. Therefore, a multidimensional approach should be adopted to improve IPC. To coordinate this approach, psychiatric institutions should appoint a professional responsible for IPC. Moreover, a balance between mental health care and IPC needs is required to sustain IPC.

Controversies and evidence on Chlamydia testing and treatment in asymptomatic women and men who have sex with men: a narrative review.

BACKGROUND: Chlamydia trachomatis (CT) is the most common bacterial sexually transmitted infection (STI) worldwide. CT is mainly asymptomatic. Test-and-treat strategies are widely implemented to prevent transmission and complications. Strategies are not without controversy in asymptomatic women and men who have sex with men (MSM). Concerns are emerging to test and treat asymptomatic persons for urogenital CT ('Controversy 1') and pharyngeal or rectal CT ('Controversy 2'), whereby testing symptomatic persons is not under debate. Opposed views in CT treatment involve using azithromycin versus doxycycline ('Controversy 3'). The objective of this review is to provide coverage of these public health and clinical controversies by reviewing the current scientific evidence. METHODS: A literature search was performed using PubMed for relevant publications between 2018 and September 2021, and iterative retrieval of additional relevant publications. RESULTS: Controversy 1. In women, the majority of asymptomatic CT are at the urogenital site, and detections mostly include viable CT. CT easily transmits to a partner and potentially also between the vaginal and rectal areas; the clinical impact of urogenital CT is established, although risks for adverse outcomes are uncertain. Wide-scale testing in asymptomatic women has not resulted in reduced prevalence. In MSM, evidence for the clinical impact of asymptomatic urogenital CT is lacking. Controversy 2. Rectal CT is common in women diagnosed with urogenital CT, but the clinical impact of asymptomatic rectal CT is uncertain. In MSM, rectal CT is common, and most CT infections are at the rectal site, yet the risk of longer term complications is unknown. In both sexes, pharyngeal CT is uncommon and has no documented clinical impact. Controversy 3. In the treatment of rectal CT, doxycycline has superior effectiveness to azithromycin. Evidence has also accumulated on the harms of test-and-treat strategies. CONCLUSIONS: Current practices vary widely, from widescale test-and-treat approaches to more individual patient- and partner-level case management. Choosing which asymptomatic people to test at what anatomic site, and whether to test or not, requires an urgent (re-)definition of the goals of testing and treating asymptomatic persons. Treatment guidelines are shifting toward universal doxycycline use, and clinical practice now faces the challenge of implementation.

Sex and age differences in the proportion of experienced symptoms by SARS-CoV-2 serostatus in a community-based cross-sectional study.

We examined the possible sex and age differences in the proportion of experienced Coronavirus Disease 2019 (COVID-19) symptoms in unaware (previously) infected adults, and their uninfected counterparts, estimated by serostatus prior to vaccination, at the end of 2020 (Wuhan strain). A cross-sectional community-based study using a convenience sample of 10 001 adult inhabitants of a southern Dutch province, heavily affected by COVID-19, was conducted. Participants donated a blood sample to indicate past infection by serostatus (positive/negative). Experienced symptoms were assessed by questionnaire, before the availability of the serological test result. Only participants without confirmed SARS-CoV-2 infection were included (n = 9715, age range 18-90 years). The seroprevalence was comparable between men (17.3%) and women (18.0%), and participants aged 18-60 years (17.3%) and aged 60 years and older (18.6%). We showed sex and age differences in the proportion experienced symptoms by serostatus in a large cohort of both unaware (untested) seropositive compared with seronegative reference participants. Irritability only differed by serostatus in men (independent of age), while stomach ache, nausea and dizziness only differed by serostatus in women aged 60 years and older. Besides, the proportion of experiencing pain when breathing and headache differed by serostatus in men aged 18-60 years only. Our study highlights the importance of taking possible sex and age differences into account with respect to acute and long-term COVID-19 outcomes. Identifying symptom profiles for sex and age subgroups can contribute to timely identification of infection, gaining importance once governments currently move away from mass testing again.

Barriers and facilitators to utilisation of public sexual healthcare services for male sex workers who have sex with men (MSW-MSM) in The Netherlands: a qualitative study.

BACKGROUND: Male sex workers who have sex with men (MSW-MSM) are a high-risk group for sexually transmitted infections (STI) including human immunodeficiency virus (HIV). Provision of sexual services by MSW-MSM has shifted to the internet. Consequently, MSW-MSM have become hidden to care for providers of sexual healthcare services (SHS). The aim of this study was to 1) assess characteristics of the MSW-MSM population and 2) assess MSW-MSM's perceived barriers and facilitators to utilise SHS provided free and anonymously by the public health STI clinic in The Netherlands. METHODS: For this qualitative study, semi-structured individual in-depth interviews were conducted with 20 MSW-MSM who worked home-based in the Dutch province of Limburg. Participants were recruited from November 2018 to June 2019 by purposive sampling until saturation was reached via 1) five websites and smartphone applications commonly used by MSW-MSM, 2) STI clinic, 3) two gay saunas. A theory-informed interview guide was developed including themes such as sexuality, sex work, SHS and barriers and facilitators to SHS utilisation. The interviews' recordings were transcribed verbatim and thematically analysed by inductive and deductive coding with Atlas.ti 8. RESULTS: The interviewed MSW-MSM were diverse in age (range: 18 - 66; median: 39.5) and mostly western European (85%). Identified barriers to SHS utilisation were lack of self-identification as homosexual and sex worker, perceived stigma on sex work and MSM, the lack of awareness of SHS and a low STI risk perception. Identified facilitators were trust in and positive attitude towards SHS, awareness of SHS's anonymous, confidential and free-of-charge nature, high STI risk perception and knowledgeable about STI/HIV. MSW-MSM-identified implications for SHS-providers were promotion of SHS on online MSW-MSM and general platforms (e.g. Facebook), offering one-on-one online and informal communication with an SHS-provider (e.g. STI clinic nurse) and providing STI (testing) information. CONCLUSION: The MSW-MSM population's diversity and identified barriers, facilitators and implications should be taken into account to optimize accessibility and utilisation of SHS for MSW-MSM in Western Europe. SHS-providers could facilitate sex work disclosure by personally asking patients about sex in exchange for money or goods in a non-judgmental manner and explaining the medical relevance of disclosure.

Changes in structure and function of social networks of independently living middle-aged and older adults in diverse sociodemographic subgroups during the COVID-19 pandemic: a longitudinal study.

BACKGROUND: Social networks, i.e., all social relationships that people have, contribute to well-being and health. Governmental measures against COVID-19 were explicitly aimed to decrease physical social contact. We evaluated ego-centric social network structure and function, and changes therein, among various sociodemographic subgroups before and during the COVID-19 pandemic. METHODS: Independently living Dutch adults aged 40 years and older participating in the SaNAE longitudinal cohort study filled in online questionnaires in 2019 and 2020. Changes in network size (network structure) and social supporters (network function) were assessed. Associations with risk for changes (versus stable) were assessed for sociodemographic subgroups (sex, age, educational level, and urbanization level) using multivariable regression analyses, adjusted for confounders. RESULTS: Of 3,344 respondents 55% were men with a mean age of 65 years (age range 41-95 in 2020). In all assessed sociodemographic subgroups, decreases were observed in mean network size (total population: 11.4 to 9.8), the number of emotional supporters (7.2 to 6.1), and practical supporters (2.2 to 1.8), and an increase in the number of informational supporters (4.1 to 4.7). In all subgroups, the networks changed to being more family oriented. Some individuals increased their network size or number of supporters; they were more often women, higher-educated, or living in rural areas. CONCLUSION: The COVID-19 pandemic impacted social networks of people aged 40 years and older, as they increased informational support and reduced the number of their social relationships, mainly in terms of emotional and practical supporters. Notably, some individuals did not show such unfavorable trends and managed to reorganize their networks to attribute social support roles more centrally.