Relative contributions of pre-pandemic factors and intra-pandemic activities to differential COVID-19 risk among migrant and non-migrant populations in the Netherlands: lessons for future pandemic preparedness.

BACKGROUND: Although risk factors for differences in SARS-CoV-2 infections between migrant and non-migrant populations in high income countries have been identified, their relative contributions to these SARS-CoV-2 infections, which could aid in the preparation for future viral pandemics, remain unknown. We investigated the relative contributions of pre-pandemic factors and intra-pandemic activities to differential SARS-CoV-2 infections in the Netherlands by migration background (Dutch, African Surinamese, South-Asian Surinamese, Ghanaians, Turkish, and Moroccan origin). METHODS: We utilized pre-pandemic (2011-2015) and intra-pandemic (2020-2021) data from the HELIUS cohort, linked to SARS-CoV-2 PCR test results from Public Health Service of Amsterdam (GGD Amsterdam). Pre-pandemic factors included socio-demographic, medical, and lifestyle factors. Intra-pandemic activities included COVID-19 risk aggravating and mitigating activities such as physical distancing, use of face masks, and other similar activities. We calculated prevalence ratios (PRs) in the HELIUS population that was merged with GGD Amsterdam PCR test data using robust Poisson regression (SARS-CoV-2 PCR test result as outcome, migration background as predictor). We then obtained the distribution of migrant and non-migrant populations in Amsterdam as of January 2021 from Statistics Netherlands. The migrant populations included people who have migrated themselves as well as their offspring. We used PRs and the population distributions to calculate population attributable fractions (PAFs) using the standard formula. We used age and sex adjusted models to introduce pre-pandemic factors and intra-pandemic activities, noting the relative changes in PAFs. RESULTS: From 20,359 eligible HELIUS participants, 8,595 were linked to GGD Amsterdam PCR test data and included in the study. Pre-pandemic socio-demographic factors (especially education, occupation, and household size) resulted in the largest changes in PAFs when introduced in age and sex adjusted models (up to 45%), followed by pre-pandemic lifestyle factors (up to 23%, especially alcohol consumption). Intra-pandemic activities resulted in the least changes in PAFs when introduced in age and sex adjusted models (up to 16%). CONCLUSION: Interventions that target pre-pandemic socio-economic status and other drivers of health inequalities between migrant and non-migrant populations are urgently needed at present to better prevent infection disparities in future viral pandemics.

Psychosocial factors may serve as additional eligibility criteria for cardiovascular risk screening in women and men in a multi-ethnic population: The HELIUS study.

Cardiovascular disease (CVD) prevention strategies include identifying and managing high risk individuals. Identification primarily occurs through screening or case finding. Guidelines indicate that psychosocial factors increase CVD risk, but their use for screening is not yet recommended. We studied whether psychosocial factors may serve as additional eligibility criteria in a multi-ethnic population without prior CVD. We performed a cross-sectional analysis using baseline data of 10,226 participants of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin aged 40-70 years, living in Amsterdam, the Netherlands. Using logistic regressions and Akaike Information Criteria, we analyzed whether psychosocial factors (educational level, employment status, occupational level, financial stress, primary earner status, mental health, stress, depression, and social isolation) improved prediction of high CVD risk (SCORE-estimated fatal and non-fatal CVD risk ≥5%) beyond eligibility criteria from history taking (smoking, obesity, family history of CVD). Next, we compared the additional predictive value of psychosocial eligibility criteria in women and men across ethnic groups, using the area under the curve (AUC). Of our sample, 32.7% had a high CVD risk. Only socioeconomic eligibility criteria (employment status and educational level) improved high CVD risk prediction (p < .001 for likelihood-ratio tests). These increased AUCs in women (from 0.563 to 0.682) and men (from 0.610 to 0.664), particularly in Dutch, South-Asian Surinamese, African Surinamese and Moroccan women, and Dutch and Moroccan men. Concluding, socioeconomic eligibility criteria may be considered as additional eligibility criteria for CVD risk screening, as they improve detection of women and men at high CVD risk.

The contribution of smoking to differences in cardiovascular disease incidence between men and women across six ethnic groups in Amsterdam, the Netherlands: The HELIUS study.

It is unclear to what extent differences in cardiovascular disease (CVD) risk between men and women are explained by differences in smoking, and whether this contribution to risk is consistent across ethnic groups. In this prospective study, we determined the contribution of smoking to differences in CVD incidence between men and women, also in various ethnic groups. We linked baseline data of 18,058 participants of six ethnic groups from the HELIUS study (Amsterdam, the Netherlands) to CVD incidence data, based on hospital admission and death records from Statistics Netherlands (2013-2019). The contribution of smoking to CVD incidence, as estimated by the population attributable fraction, was higher in men than in women, overall (24.1% versus 15.6%) and across most ethnic groups. Among Dutch participants, however, the contribution of smoking was higher among women (21.0%) than men (16.2%). Using Cox regression analyses, we observed that differences in smoking prevalence explained 22.0% of the overall lower hazard for CVD in women compared to men. Smoking contributed minimally to the lower hazards for CVD in women among participants of Dutch (0%), Ghanaian (4.9%) and Moroccan origin (0%), but explained 28.6% and 48.6% of the lower hazards in women in South-Asian Surinamese and African Surinamese groups, respectively. While smoking prevention and cessation may lead to lower CVD incidence in most groups of men and women, it may not substantially reduce disparities in CVD risk between men and women in most ethnic groups.

Cardiovascular risk profile after a complicated pregnancy across ethnic groups: The HELIUS study.

AIMS: Little is known about how pregnancy complications and cardiovascular disease (CVD) risk are associated, specifically among ethnic minorities. In this study we examined this association in women from six ethnic groups, and the potential value of pregnancy complications as eligibility criterion for CVD risk screening. METHODS: We conducted a cross-sectional study combining obstetric history from the Dutch perinatal registry with data on cardiovascular risk up to 15 years after pregnancy from the multi-ethnic HELIUS study. We included 2,466 parous women of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin. Associations were studied across ethnicities and predictive value of pregnancy complications for CVD risk factors above traditional eligibility criteria for CVD risk screening was assessed using Poisson regression. RESULTS: History of hypertensive disorders of pregnancy and preterm birth were associated with higher prevalence of chronic hypertension and chronic kidney disease across most groups (prevalence ratio 1.6-1.9). Gestational diabetes mellitus was associated with increased type 2 diabetes mellitus risk, particularly in ethnic minority groups (prevalence ratio 4.5-7.7). Associations did not significantly differ across ethnic groups. The prediction models did not improve substantially after adding pregnancy complications to traditional eligibility criteria for CVD risk screening. CONCLUSION: History of hypertensive disorders of pregnancy, preterm birth and gestational diabetes mellitus is associated with CVD risk factors in parous women, without evidence of a differential association across ethnic groups. However, addition of pregnancy complications to traditional eligibility criteria for CVD risk screening does not substantially improve the prediction of prevalent CVD risk factors.

Women of different ethnic backgrounds who had pregnancy complications (high blood pressure or diabetes during pregnancy, or who delivered their baby too early) have a higher risk of heart disease later in life. Screening for a high risk of heart disease is important, because interventions may help to prevent heart disease. Currently, general practitioners use several criteria to select women for screening, such as heart disease among close relatives or smoking. In our study in women in whom these 'traditional' criteria for screening were measured, the pregnancy complications did not help to find more women with a high risk. Yet, pregnancy complications may be a signal for both patients and healthcare professionals to regularly consider the need for screening. Women who had high blood pressure in pregnancy or delivered their baby too early had up to two times more often chronic hypertension or kidney disease later in life. Women who had diabetes in pregnancy, had up to eight times more type 2 diabetes later in life. Women of South-Asian Surinamese, African Surinamese and Ghanaian origin living in the Netherlands more often had pregnancy complications and cardiovascular risk factors than women with a Dutch background.

Prospective analysis of gender-related characteristics in relation to cardiovascular disease.

OBJECTIVE: Differences in cardiovascular disease (CVD) incidence between men and women have been widely reported. Next to sex-related (biological) characteristics, gender-related (sociocultural) characteristics may partly explain how these differences arise. In this exploratory study, we examined the associations between selected gender-related characteristics and CVD incidence. METHODS: We linked baseline data of 18 058 participants without CVD from the population-based, multiethnic HEalthy LIfe in an Urban Setting study (Amsterdam, the Netherlands) to CVD incidence data, based on hospital admission and death records from Statistics Netherlands in 2013-2018. Using Cox regression analyses, we studied associations of time spent on household work, doing home repairs, primary earner status, type of employment, working in a male-dominated or female-dominated occupation and desire for emotional support with CVD incidence, stratified by sex. Analyses were adjusted for age, ethnicity and socioeconomic status. RESULTS: In men, gender-related characteristics were not associated with higher CVD incidence. In women, homemakers had a higher hazard for CVD compared with full-time workers (HR 2.34, 95% CI 1.35 to 4.04), whereas those spending a moderate amount of time on household work had a lower hazard for CVD than those spending little time (HR 0.56, 95% CI 0.34 to 0.95). CONCLUSION: Although we found no evidence for associations between gender-related characteristics and CVD incidence in men, being the homemaker and moderate time spent on household work appeared to be associated with CVD incidence in women. Thus, attention to gender-related characteristics might in future help to identify subgroups that may benefit from additional prevention strategies.

The association between gender-related characteristics and type 2 diabetes risk in a multi-ethnic population: The HELIUS study.

BACKGROUND AND AIMS: Men and women have different type 2 diabetes mellitus (T2DM) risks, which have been reported across populations of different ethnicity. Where differences in T2DM risk for sex (biological) have been studied, research on gender (socio-cultural) and T2DM risk is lacking. We explored, in a multi-ethnic population, the association of six gender-related characteristics with incident T2DM over 3 years, and the mediation by known risk factors for T2DM. METHODS AND RESULTS: We included 9605 women and 7080 men of the multi-ethnic HELIUS study (Amsterdam, the Netherlands). We studied associations between gender-related characteristics and incident T2DM, using Cox regression. After a median of 3.0 years (IQR 2.0; 4.0), 198 (2.1%) women and 137 (1.9%) men developed T2DM. A lower T2DM risk was observed in those not being the primary earner (HR 0.67; 95% CI 0.47; 0.93) and a higher desired level of social support (HR 0.62; 95% CI 0.44; 0.87). Hours spent on household work, home repairs, type of employment and male- or female-dominated occupation were not associated with T2DM incidence. No evidence for effect modification by biological sex or ethnicity was found. Known risk factors of T2DM did not mediate the observed associations. CONCLUSION: Gender-related characteristics, not being the primary earner and a higher desired social support were associated with reduced T2DM risk, and this was not mediated by known risk factors for T2DM.

Sex differences in incidence of out-of-hospital cardiac arrest across ethnic and socioeconomic groups: A population-based cohort study in the Netherlands.

BACKGROUND: Insight into the occurrence of out-of-hospital cardiac arrest (OHCA) within general populations may help to target prevention strategies. Case registries suggest that there may be substantial differences in emergency medical service (EMS)-attended OHCA incidence between men and women, but relative sex differences across ethnic groups and socioeconomic (SES) groups have not been studied. We investigated sex differences in OHCA incidence, overall and across these subgroups. METHODS: We performed a retrospective population-based cohort study, combining individual-level data on ethnicity and income (as SES measure) from Statistics Netherlands of all men and women aged ≥25 years living in one study region in the Netherlands on 01-01-2009 (n = 1,688,285) with prospectively collected EMS-attended OHCA cases (n = 5676) from the ARREST registry until 31-12-2015. We calculated age-standardised incidence rates of OHCA. Sex differences were assessed with Cox proportional hazards regression analyses, adjusted for age, ethnicity and income, in the overall population, and across ethnic and SES groups. RESULTS: The age-standardised incidence rate of OHCA was lower in women than in men (30.9 versus 87.3 per 100,000 person-years), corresponding with a hazard ratio (HR) of 0.33 (95% confidence interval [CI] 0.31-0.35). These sex differences in hazard for OHCA existed in all income quintiles (HR range: 0.30-0.35) and ethnic groups (HR range: 0.19-0.40), except among Moroccans (HR 0.89, 95% CI 0.51-1.57). CONCLUSION: Women have a substantial, yet lower OHCA incidence rate than men. The magnitude of these sex differences did not vary across social strata.

Gender inequality and the double burden of disease in low-income and middle-income countries: an ecological study.

INTRODUCTION: Many low-income and middle-income countries (LMIC) suffer from a double burden of infectious diseases (ID) and non-communicable diseases (NCD). Previous research suggests that a high rate of gender inequality is associated with a higher ID and NCD burden in LMIC, but it is unknown whether gender inequality is also associated with a double burden of disease. In this ecological study, we explored the association between gender inequality and the double burden of disease in LMIC. METHODS: For 108 LMIC, we retrieved the Gender Inequality Index (GII, scale 0-1) and calculated the double burden of disease, based on disability-adjusted life-years for a selection of relevant ID and NCD, using WHO data. We performed logistic regression analysis to study the association between gender inequality and the double burden of disease for the total population, and stratified for men and women. We adjusted for income, political stability, type of labour, urbanisation, government health expenditure, health infrastructure and unemployment. Additionally, we conducted linear regression models for the ID and NCD separately. RESULTS: The GII ranged from 0.13 to 0.83. A total of 37 LMIC had a double burden of disease. Overall, the adjusted OR for double burden of disease was 1.05 per 0.01 increase of GII (95% CI 0.99 to 1.10, p=0.10). For women, there was a borderline significant positive association between gender inequality and double burden of disease (OR 1.05, 95% CI 1.00 to 1.11, p=0.06), while there was no association in men (OR 0.99, 95% CI 0.95 to 1.04, p=0.75). CONCLUSION: We found patterns directing towards a positive association between gender inequality and double burden of disease, overall and in women. This finding suggests the need for more attention for structural factors underlying gender inequality to potentially reduce the double burden of disease.

Gender-related characteristics and disparities in estimated cardiovascular disease risk in a multi-ethnic general population: The HELIUS study.

BACKGROUND: Differences in cardiovascular disease (CVD) risk between men and women have been widely reported. However, risk differences by gender-related characteristics (sociocultural characteristics) have been poorly studied, although these characteristics may associate with cardiovascular health. We explored associations of three gender-related characteristics with estimated CVD risk in men and women within various ethnic groups. METHODS: We used baseline data of 9185 participants of six ethnic groups of the HELIUS study (Amsterdam, the Netherlands), aged 40-65 years, without CVD and diabetes. We studied the associations of three gender-related characteristics (time per week doing household work, primary earner status, performing a male- or female-dominated occupation) with CVD risk as estimated with SCORE algorithm using linear regression analyses. Analyses were stratified by sex, and adjusted for age and socioeconomic status. Next, we explored whether associations differed across ethnic groups. RESULTS: Individuals who were no primary earners had a 6% (beta 0.94; 95% CI 0.88-1.01; men) and 8% (beta 0.92; 95% CI 0.90-0.95; women) lower CVD risk than primary earners. Performing a female-dominated versus male-dominated occupation was associated with a 7% lower CVD risk in women (beta 0.93; 95% CI 0.88-0.99), but not in men. Time spent on household work was not associated with CVD risk. These associations were mostly consistent across ethnic groups. CONCLUSION: Masculine gender-related characteristics were associated with a higher estimated CVD risk across ethnic groups, specifically, being the primary earner (men and women) and performing a male-dominated occupation (women). Our findings may in future help to identify specific high-risk groups.

Do sex differences in the prevalence of ECG abnormalities vary across ethnic groups living in the Netherlands? A cross-sectional analysis of the population-based HELIUS study.

OBJECTIVES: Major ECG abnormalities have been associated with increased risk of cardiovascular disease (CVD) burden in asymptomatic populations. However, sex differences in occurrence of major ECG abnormalities have been poorly studied, particularly across ethnic groups. The objectives were to investigate (1) sex differences in the prevalence of major and, as a secondary outcome, minor ECG abnormalities, (2) whether patterns of sex differences varied across ethnic groups, by age and (3) to what extent conventional cardiovascular risk factors contributed to observed sex differences. DESIGN: Cross-sectional analysis of population-based study. SETTING: Multi-ethnic, population-based Healthy Life in an Urban Setting cohort, Amsterdam, the Netherlands. PARTICIPANTS: 8089 men and 11 369 women of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin aged 18-70 years without CVD. OUTCOME MEASURES: Age-adjusted and multivariable logistic regression analyses were performed to study sex differences in prevalence of major and, as secondary outcome, minor ECG abnormalities in the overall population, across ethnic groups and by age-groups (18-35, 36-50 and >50 years). RESULTS: Major and minor ECG abnormalities were less prevalent in women than men (4.6% vs 6.6% and 23.8% vs 39.8%, respectively). After adjustment for conventional risk factors, sex differences in major abnormalities were smaller in ethnic minority groups (OR ranged from 0.61 in Moroccans to 1.32 in South-Asian Surinamese) than in the Dutch (OR 0.49; 95% CI 0.36 to 0.65). Only in South-Asian Surinamese, women did not have a lower odds than men (OR 1.32; 95% CI 0.96 to 1.84). The pattern of smaller sex differences in ethnic minority groups was more pronounced in older than in younger age-groups. CONCLUSIONS: The prevalence of major ECG abnormalities was lower in women than men. However, sex differences were less apparent in ethnic minority groups. Conventional risk factors did not contribute substantially to observed sex differences.

Global etiology of bacterial meningitis: A systematic review and meta-analysis.

Bacterial meningitis is a global public health concern, with several responsible etiologic agents that vary by age group and geographical area. The aim of this systematic review and meta-analysis was to assess the etiology of bacterial meningitis in different age groups across global regions. PubMed and EMBASE were systematically searched for English language studies on bacterial meningitis, limited to articles published in the last five years. The methodological quality of the studies was assessed using a customized scoring system. Meta-analyses were conducted to determine the frequency (percentages) of seven bacterial types known to cause meningitis: Escherichia coli, Haemophilus influenzae, Neisseria meningitidis, Streptococcus pneumoniae, group B Streptococcus agalactiae, Staphylococcus aureus, and Listeria monocytogenes, with results being stratified by six geographical regions as determined by the World Health Organization, and seven age groups. Of the 3227 studies retrieved, 56 were eligible for the final analysis. In all age groups, S. pneumoniae and N. meningitidis were the predominant pathogens in all regions, accounting for 25.1-41.2% and 9.1-36.2% of bacterial meningitis cases, respectively. S. pneumoniae infection was the most common cause of bacterial meningitis in the 'all children' group, ranging from 22.5% (Europe) to 41.1% (Africa), and in all adults ranging from 9.6% (Western Pacific) to 75.2% (Africa). E. coli and S. pneumoniae were the most common pathogens that caused bacterial meningitis in neonates in Africa (17.7% and 20.4%, respectively). N. meningitidis was the most common in children aged ±1-5 years in Europe (47.0%). Due to paucity of data, meta-analyses could not be performed in all age groups for all regions. A clear difference in the weighted frequency of bacterial meningitis cases caused by the different etiological agents was observed between age groups and between geographic regions. These findings may facilitate bacterial meningitis prevention and treatment strategies.

Reproductive factors in relation to heart failure in women: A systematic review.

BACKGROUND: The biological mechanisms underlying the sex-related differences in risk of heart failure are still not well understood. The aim of this review was to provide an overview of the current evidence on the association between reproductive factors and risk of heart failure in women. METHODS: A systematic review of the literature was conducted. PubMed and Embase databases were searched for publications on the following reproductive factors as potential risk factors for heart failure in women: age at menarche, duration and frequency of the menstrual cycle, reproductive lifespan, use of contraception, polycystic ovarian syndrome (PCOS), pregnancy characteristics (e.g. parity), pregnancy complications (e.g. preeclampsia), induced abortion, history of breastfeeding, fertility status, use of assisted reproductive methods, hysterectomy, age at menopause, and use of hormone replacement therapy (HRT). RESULTS: Twenty-one studies were eligible for inclusion. Hypertensive pregnancy disorders, preterm delivery or small-for-gestational-age (SGA) infants, shorter reproductive duration, and early menopause were risk factors for heart failure in women. It was suggested that PCOS, fertility therapy, gestational diabetes, and age at first pregnancy were not related to risk of heart failure, but a potential relation cannot be fully excluded as most studies were not of sufficient quality. Conflicting results were found for the associations between risk of heart failure and hysterectomy, gravidity and parity, and HRT. CONCLUSION: Although some reproductive factors were considered risk factors for heart failure in women, the results were mostly conflicting or inconclusive. Further research is needed to confirm and expand the current evidence on the association between reproductive factors and risk of heart failure.

Comparing viral load metrics and evaluating their use for HIV surveillance.

OBJECTIVES: To investigate the value of in-care viral load (ICVL) and other viral load (VL) metrics for HIV surveillance by comparing time trends and associations with numbers of new HIV diagnoses. METHODS: Data from 20,740 HIV patients registered in the Dutch ATHENA-cohort between 2002 and 2013 were used. We compared: six ICVL metrics (i.e. mean of the mean/first/last/highest log VL, median of the median log VL, first log VL for newly diagnosed combined with mean log VL for all others), log VL at diagnosis, proportion of patients with transmission risk (>400 copies/ml) or suppressed VL (≤200 copies/ml). Subgroup differences were assessed using Kruskal-Wallis and chi-square tests. Negative binomial regression was used for studying associations between VL metrics and numbers of new diagnoses 1-4 years later. RESULTS: Most ICVL metrics showed similar decreasing trends over time. Differences in covariables were found for all VL metrics. Mean ICVL showed the strongest association with new diagnoses: a decrease of one log unit in mean ICVL was associated with a 21% decrease in new diagnoses two years later. CONCLUSIONS: VL metrics may be of value for enhancing HIV surveillance by identifying subgroup differences in impact of treatment on viral suppression, and by predicting numbers of new diagnoses in subsequent years.