Differences in non-positive intention to accept the COVID-19 booster vaccine between three countries in the cross-border region Meuse-Rhine Euroregion: The Netherlands, Belgium, and Germany.

COVID-19 booster vaccination has shown to add to the protection against infection with SARS-CoV2 and subsequent severe disease. This longitudinal cross-border study aimed to identify factors associated with COVID-19 booster vaccine intentions in an initially vaccinated adult population living in the Meuse-Rhine Euroregion (EMR; including the Netherlands, Belgium, and Germany) and differences between countries. Data collection took place in autumn of 2021 and consisted of online questionnaires sent to a random sample of the population based on governmental registries. Data from 3,319 fully and partially vaccinated adults were used to examine determinants of non-positive intention for a booster vaccination (i.e., uncertain or do not want), using multivariable logistic regression analyses weighted by age group, sex, and country. Compared to German residents, Dutch residents (OR = 2.4) and Belgian residents (OR = 1.4) were more likely to be uncertain or not want to receive a booster vaccine in September-October 2021. Factors independently associated with non-positive intention were female sex (OR = 1.6), absence of comorbidities (OR = 1.3), time since last vaccination less than 3 months ago for those fully vaccinated (OR = 1.6), being partially vaccinated (OR = 3.6), a negative experience with communication of COVID-19 measures (OR = 2.2), and regarding measures as ineffective (OR = 1.1). Results indicate that booster vaccine intentions differ between countries in the cross border Meuse-Rhine Euroregion. Non-positive intention for the booster vaccine is prevalent in all three countries of the EMR, but to a different extent, as shown in this study. Cross-border collaboration and sharing information and knowledge about vaccination strategies could play a role in limiting the impact of COVID-19.

Facility- and ward-level factors associated with SARS-CoV-2 outbreaks among residents in long-term care facilities: a retrospective cohort study

Background Long-term care facilities (LTCFs) have been disproportionately impacted by COVID-19. Yet, the reasons why certain LTCFs are affected more by outbreaks are poorly understood. Objective To identify facility- and ward-level factors associated with SARS-CoV-2 outbreaks among LTCF residents. Methods We conducted a retrospective cohort study of multiple Dutch LTCFs (N=60;with 298 wards providing care for ∼5600 residents) from September 2020-June 2021. A dataset was constructed linking SARS-CoV-2 cases among LTCF residents to facility- and ward-level factors. Multilevel logistic regression analyses examined the associations between these factors and the likelihood of a SARS-CoV-2 outbreak among residents. Results During periods of the classic variant, mechanical recirculation of air was associated with significantly increased odds of a SARS-CoV-2 outbreak. During periods of the alpha variant, factors associated with significantly increased odds included large ward size (≥21 beds), wards providing psychogeriatric care, fewer restrictions on staff movement within and between facilities, and a greater number of cases among staff (>10 cases). Conclusions Policy and protocols on reducing resident density, staff movement, and mechanical recirculation of air in buildings are recommended to enhance outbreak preparedness in LTCFs. The implementation of low-threshold preventive measures among psychogeriatric residents is important since they appear as a particularly vulnerable group.

Acceptance of vaccination against pertussis, COVID-19 and influenza during pregnancy: a cross-sectional study.

BACKGROUND: This study aims to assess the uptake of maternal pertussis and COVID-19 vaccination and the intention towards accepting the maternal influenza vaccination. Insights into different socio-demographic factors related to maternal vaccination coverage might help to address vaccine acceptance and improve maternal vaccine uptake in the future. METHODS: We conducted a cross-sectional survey among pregnant women and recent mothers, up to 6 months post-partum. The primary outcome measures of this study were behaviour for maternal pertussis and COVID-19 vaccination, and maternal influenza vaccination intention. Associations between socio-demographic factors and maternal pertussis vaccination and maternal COVID-19 vaccination behaviour; and socio-demographic factors and maternal influenza vaccination intention were assessed using binary logistic regression analyses. RESULTS: In total 1361 respondents filled out the questionnaire. Almost all women (95%) were vaccinated against pertussis during pregnancy, while almost two-third were vaccinated against COVID-19 during pregnancy (58%) and almost one-third (28%) had a positive intention towards receiving the maternal influenza vaccination. Results show that young maternal age and low education level were associated with lower maternal vaccination acceptance. CONCLUSION: Vaccination campaigns focusing on the severity of diseases that are prevented, are needed to increase maternal vaccine acceptance in younger and low-educated pregnant women. We expect that differences in vaccination coverage between the three maternal vaccinations might partly be explained by existing recommendations, campaigns and whether the vaccination is part of the national immunisation program.

Facility- and ward-level factors associated with SARS-CoV-2 outbreaks among residents in long-term care facilities: A retrospective cohort study.

OBJECTIVES: Long-term care facilities (LTCFs) have been disproportionately impacted by COVID-19. Yet, the reasons why certain LTCFs are affected more by outbreaks are poorly understood. This study aimed to identify the facility- and ward-level factors associated with SARS-CoV-2 outbreaks among LTCF residents. METHODS: We conducted a retrospective cohort study of multiple Dutch LTCFs (N = 60; with 298 wards providing care for ∼5600 residents) from September 2020 to June 2021. A dataset was constructed linking SARS-CoV-2 cases among LTCF residents to facility- and ward-level factors. Multilevel logistic regression analyses examined the associations between these factors and the likelihood of a SARS-CoV-2 outbreak among residents. RESULTS: During periods of the Classic variant, the mechanical recirculation of air was associated with significantly increased odds of a SARS-CoV-2 outbreak. During periods of the Alpha variant, the factors associated with significantly increased odds included large ward size (≥21 beds), wards providing psychogeriatric care, fewer restrictions on staff movement between wards and facilities, and a greater number of cases among staff (>10 cases). CONCLUSION: Policy and protocols on reducing resident density, staff movement, and mechanical recirculation of air in buildings are recommended to enhance outbreak preparedness in LTCFs. The implementation of low-threshold preventive measures among psychogeriatric residents is important because they appear as a particularly vulnerable group.

Design and recruitment of a large-scale cohort study on prevalence, risk factors and impact evaluation of post-COVID-19 condition and its wider long-term social, mental, and physical health impact: The PRIME post-COVID study.

Background: Persistent symptoms, described as long COVID or post-COVID-19 condition, pose a potential public health problem. Here, the design and recruitment of the PRIME post-COVID study is described. PRIME post-COVID is a large-scale population-based observational study that aims to improve understanding of the occurrence, risk factors, social, physical, mental, emotional, and socioeconomic impact of post-COVID-19 condition. Methods: An observational open cohort study was set up, with retrospective and prospective assessments on various health-conditions and health-factors (medical, demographic, social, and behavioral) based on a public health COVID-19 test and by self-report (using online questionnaires in Dutch language). Invited for participation were, as recorded in a public health registry, adults (18 years and older) who were tested for COVID-19 and had a valid Polymerase Chain Reaction (PCR) positive or negative test result, and email address. In November 2021, 61,655 individuals were invited by email to participate, these included all eligible adults who tested PCR positive between 1 June 2020 and 1 November 2021, and a sample of adults who tested negative (2:1), comparable in distribution of age, sex, municipality of residence and year-quarter of testing. New recruitment periods are planned as well. Participants are followed over time by regular follow-up measurements. Data are analyzed using the appropriate data-analyses methods. Discussion: The PRIME post-COVID study will provide insights into various health-related aspects of post-COVID-19 condition in the context of various stages of the COVID-19 pandemic. Results will inform practical guidance for society, clinical and public health practice for the prevention and care for long-term impact of COVID-19. Trial registration ClinicalTrialsgov identifier: NCT05128695.

Investigating SARS-CoV-2 breakthrough infections per variant and vaccine type.

Breakthrough SARS-CoV-2 infections have been reported in fully vaccinated individuals, in spite of the high efficacy of the currently available vaccines, proven in trials and real-world studies. Several variants of concern (VOC) have been proffered to be associated with breakthrough infections following immunization. In this study, we investigated 378 breakthrough infections recorded between January and July 2021 and compared the distribution of SARS-CoV-2 genotypes identified in 225 fully vaccinated individuals to the frequency of circulating community lineages in the region of South Limburg (The Netherlands) in a week-by-week comparison. Although the proportion of breakthrough infections was relatively low and stable when the Alpha variant was predominant, the rapid emergence of the Delta variant lead to a strong increase in breakthrough infections, with a higher relative proportion of individuals vaccinated with Vaxzevria or Jcovden being infected compared to those immunized with mRNA-based vaccines. A significant difference in median age was observed when comparing fully vaccinated individuals with severe symptoms (83 years) to asymptomatic cases (46.5 years) or individuals with mild-to-moderate symptoms (42 years). There was no association between SARS-CoV-2 genotype or vaccine type and disease symptoms. Furthermore, the majority of adaptive mutations were concentrated in the N-terminal domain of the Spike protein, highlighting its role in immune evasion. Interestingly, symptomatic individuals harbored significantly higher SARS-CoV-2 loads than asymptomatic vaccinated individuals and breakthrough infections caused by the Delta variant were associated with increased viral loads compared to those caused by the Alpha variant. In addition, we investigated the role of the Omicron variant in causing breakthrough infections by analyzing 135 samples that were randomly selected for genomic surveillance during the transition period from Delta to Omicron. We found that the proportion of Omicron vs. Delta infections was significantly higher in individuals who received a booster vaccine compared to both unvaccinated and fully vaccinated individuals. Altogether, these results indicate that the emergence of the Delta variant and in particular Omicron has lowered the efficiency of particular vaccine types to prevent SARS-CoV-2 infections and that, although rare, the elderly are particularly at risk of becoming severely infected as the consequence of a breakthrough infection.

Evaluation of symptomatology and viral load among residents and healthcare staff in long-term care facilities: A coronavirus disease 2019 retrospective case-cohort study.

OBJECTIVES: We evaluated COVID-19 symptoms, case fatality rate (CFR), and viral load among all Long-Term Care Facility (LTCF) residents and staff in South Limburg, the Netherlands (February 2020-June 2020, wildtype SARS-CoV-2 Wuhan strain). METHODS: Patient information was gathered via regular channels used to notify the public health services. Ct-values were obtained from the Maastricht University Medical Centre laboratory. Logistic regression analyses were performed to assess associations between COVID-19, symptoms, CFR, and viral load. RESULTS: Of 1,457 staff and 1,540 residents, 35.1% and 45.2% tested positive for COVID-19. Symptoms associated with COVID-19 for female staff were fever, cough, muscle ache and loss of taste and smell. Associated symptoms for men were cough, and loss of taste and smell. Associated symptoms for residents were subfebrility, fatigue, and fever for male residents only. LTCF residents had a higher mean viral load compared to staff. Male residents had a higher CFR (35.8%) compared to women (22.5%). Female residents with Ct-values 31 or less had increased odds of mortality. CONCLUSIONS: Subfebrility and fatigue seem to be associated with COVID-19 in LTCF residents. Therefore, physicians should also consider testing residents who (only) show aspecific symptoms whenever available resources prohibit testing of all residents. Viral load was higher in residents compared to staff, and higher in male residents compared to female residents. All COVID-19 positive male residents, as well as female residents with a medium to high viral load (Ct-values 31 or lower) should be monitored closely, as these groups have an overall increased risk of mortality.

Intention to use and acceptability of home-based sexual health care among men who have sex with men who previously attended clinic-based sexual health care.

The COVID-19 pandemic has temporarily disrupted access to clinic-based sexual health care for men who have sex with men (MSM) in the Netherlands. The importance of home-based sexual health care has been underpinned as an extension of clinic-based care. This paper aims to assess intention to use, and acceptability of home-based sexual health care among MSM who previously attended clinic-based sexual health care. In November 2020, 424 MSM who had attended an STI clinic pre-pandemic were invited to participate in an online survey; 154 MSM completed the survey (response 36%). Intention to use self-sampling STI/HIV tests was assessed (median; scale 0-100) and compared across sociodemographic and sexual behavior characteristics by Kruskal-Wallis H tests. Descriptive analyses provided insights in acceptability of home-based sexual health care. Of participants (median age 47), 60.4% (93/154) tested for STI/HIV in the past 6 months, most of them attended a clinic. The median score on intention to use self-sampling tests was 86.5 (SD = 33.4) and did not differ by sociodemographic or sexual behavioral characteristics (all p-values > 0.1). Participants were positive toward online sexual health counseling (median attitude = 75.0, SD = 29.6) and their main preferred topics were PrEP use and STI/HIV testing. MSM who attended clinic-based care expressed intention to use self-sampling tests and a positive attitude toward online sexual health counseling. Home-based sexual health care elements are not currently integrated within Dutch clinic-based sexual health care and should be considered an addition for continued provision of care and extended reach of MSM.

Increased transmissibility of SARS-CoV-2 alpha variant (B.1.1.7) in children: three large primary school outbreaks revealed by whole genome sequencing in the Netherlands.

BACKGROUND: Variant of concern (VOC) SARS-CoV-2 alpha variant (B.1.1.7) was the dominant strain in the Netherlands between March 2021-June 2021. We describe three primary school outbreaks due to the alpha variant using whole genome sequencing with evidence of large-scale transmission among children, teachers and their household contacts. METHOD: All outbreaks described were investigated by the South Limburg Public Health Service, the Netherlands. A case was defined as an individual with a real-time polymerase chain reaction test or antigen test positive for SARS-CoV-2. Whole genome sequencing was performed on random samples from at least one child and one teacher of each affected class. RESULTS: Peak attack rates in classes were 53%, 33% and 39%, respectively. Specific genotypes were identified for each school across a majority of affected classes. Attack rates were high among staff members, likely to promote staff-to-children transmission. Cases in some classes were limited to children, indicating child-to-child transmission. At 39%, the secondary attack rate (SAR) in household contacts of infected children was remarkably high, similar to SAR in household contacts of staff members (42%). SAR of household contacts of asymptomatic children was only 9%. CONCLUSION: Our findings suggest increased transmissibility of the alpha variant in children compared to preceding non-VOC variants, consistent with a substantial rise in the incidence of cases observed in primary schools and children aged 5-12 since the alpha variant became dominant in March 2021. Lack of mandatory masking, insufficient ventilation and lack of physical distancing also probably contributed to the school outbreaks. The rise of the delta variant (B.1.617.2) since July 2021 which is estimated to be 55% more transmissible than the alpha variant, provides additional urgency to adequate infection prevention in school settings.

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.

Infections with the SARS-CoV-2 Delta variant exhibit fourfold increased viral loads in the upper airways compared to Alpha or non-variants of concern.

There has been a growing body of evidence that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta variant (B.1.617.2) shows enhanced transmissibility and increased viral loads compared to other variants. A recent study has even suggested that respiratory samples from people infected with the Delta variant can harbor up to 1000 times higher viral loads compared to samples with variants that are more closely related to the original Wuhan strain, although the sample size of this study (n = 125) was very limited. Here, we have compared the viral load in 16,185 samples that were obtained in periods during which non-VOC, the Alpha (B.1.1.7) or Delta variant (B.1.617.2) were dominant as evidenced by genomic surveillance. We found that the Delta variant contained about fourfold higher viral loads across all age groups compared to the non-VOC or Alpha variants, which is significantly lower than reported earlier. Interestingly, the increased viral load for the Delta variant seemed to be age-dependent, regardless of sex, as the viral load was about 14-fold higher for Delta compared to the non-VOC or Alpha variant in age group 0-20 years and fourfold higher in age group 21-40 years, while there was no difference in viral load between variants in age groups 41-60 and 61+ years, most likely as a consequence of a higher degree of vaccination in the older age groups.

Psychosocial and organizational barriers and facilitators of meningococcal vaccination (MenACWY) acceptance among adolescents and parents during the Covid-19 pandemic: a cross-sectional survey.

BACKGROUND: This study aimed to identify differences and similarities among adolescents and parents in various psychosocial factors influencing meningococcal ACWY (MenACWY) vaccination acceptance. Besides, the impact of the Covid-19 pandemic was assessed as well as resulting organizational adjustments. METHODS: We conducted a cross-sectional survey among adolescents that attended the appointment for the MenACWY vaccination in South Limburg between May and June 2020, and their parents. Independent t-tests and χ2 test were performed to explore differences in psychosocial and organisational factors between adolescents and parents. RESULTS: In total, 592 adolescents (20%) and 1197 parents (38%) filled out the questionnaire. Adolescents scored lower on anticipated negative affect towards MenACWY vaccination refusal [t (985.688) = - 9.32; ρ < 0.001], moral norm towards MenACWY vaccination acceptance [t (942.079) = - 10.38; ρ < 0.001] and knowledge about the MenACWY vaccination and meningococcal disease [t (1059.710) = - 11.24; ρ < 0.001]. Both adolescents and parents reported a social norm favouring accepting childhood vaccinations, but adolescent scored higher [t (1122.846) = 23.10; ρ < 0.001]. The Covid-19 pandemic did barely influence the decision to accept the MenACWY vaccination. Only 6% of the participants indicated that Covid-19 influenced their decision. In addition, the individual vaccination appointment was rated very positive. Most adolescents (71.5%) and parents (80.6%) prefer future vaccinations to be offered individually rather than having mass vaccinations sessions. CONCLUSIONS: This study provides an indication of which psychosocial and organisational factors should be addressed in future MenACWY vaccination campaigns. Individual vaccination appointments for adolescents should be considered, taking the costs and logistical barriers into account.

Exposure factors associated with SARS-CoV-2 seroprevalence during the first eight months of the COVID-19 pandemic in the Netherlands: A cross-sectional study.

BACKGROUND: The availability of valid Severe Acute Respiratory Syndrome Coronvirus-2 (SARS-CoV-2) serological tests overcome the problem of underestimated cumulative Coronavirus Disease 2019 (COVID-19) cases during the first months of the pandemic in The Netherlands. The possibility to reliably determine the number of truly infected persons, enabled us to study initial drivers for exposure risk in the absence of routine testing. Numerous activities or circumstances can accelerate virus spread, here defined as exposure factors. Hence, we aimed to evaluate a wide variety of demographic, behavioural and social exposure factors associated with seropositivity during the first eight months of the pandemic in Limburg, The Netherlands. METHODS: SARS-CoV-2 point-seroprevalence was determined cross-sectionally to indicate previous infection in a convenience sample of minimal 10,000 inhabitants of the study province. All adult (18+ years) inhabitants of the study province were eligible to register themselves for participation. Once the initial 10,000 registrations were reached, a reserve list was kept to ensure sufficient participants. Possible exposure factors were mapped by means of an extensive questionnaire. Associated exposure factors were determined using univariable and multivariable logistic regression models. RESULTS: Seropositivity was established in 19.5% (n = 1,948) of the 10,001 participants (on average 49 years old (SD = 15; range 18-90 years), majority women (n = 5,829; 58.3%). Exposure factors associated with seropositivity included current education, working in healthcare and not working from home, and being a member of three or four associations or clubs. Specifically for February-March 2020, visiting an après-ski bar during winter sports in Austria, travelling to Spain, celebrating carnival, and participating in a singing activity or ball sport were associated with seropositivity. CONCLUSIONS: Our results confirm that relevant COVID-19 exposure factors generally reflected circumstances where social distancing was impossible, and the number and duration of contacts was high, in particular for indoor activities.

Routine universal testing versus selective or incidental testing for oropharyngeal Chlamydia trachomatis in women in the Netherlands: a retrospective cohort study.

BACKGROUND: Pharyngeal Chlamydia trachomatis in women might contribute to autoinoculation and transmission to sexual partners. Data for effectiveness of different testing practices for pharyngeal C trachomatis are scarce. We therefore aimed to assess the prevalence of pharyngeal C trachomatis, determinants, and effectiveness of different testing practices in women. METHODS: We did a retrospective cohort study, in which surveillance data for all women visiting sexually transmitted infection clinics in all regions in the Netherlands between Jan 1, 2008, and Dec 31, 2017, were used. We collected consultation-level data and individual-level data from 2016 onwards for sociodemographic characteristics, sexual behaviour in the past 6 months, self-reported symptoms, and STI diagnoses. The primary outcome was the positivity rate of pharyngeal C trachomatis infection compared between routine universal testing (>85% tested pharyngeally per clinic year), selective testing (5-85% tested pharyngeally per clinic year), and incidental testing (<5% pharyngeally tested per clinic year). We calculated the number of missed infections by extrapolating the positivity rate assessed by routine universal testing to all selectively tested women. We used multivariable generalised estimating equations logistic regression analyses to assess independent risk factors for pharyngeal C trachomatis and used the assessed risk factors as testing indicators for comparing alternative testing scenarios. FINDINGS: Between Jan 1, 2008, and Dec 31, 2017, a total of 550 615 consultations with at least one C trachomatis test was recorded, of which 541 945 (98·4%) consultations (including repeat visits) were included in this analysis. Pharyngeal C trachomatis positivity was lower in the routine universal testing group than in the selective testing group (1081 [2·4%; 95% CI 2·2-2·5] of 45 774 vs 3473 [2·9%; 2·8-3·0] of 121 262; p<0·0001). The positivity rate was also higher among consultations done in the incidental testing group (44 [4·1%; 95% CI 3·1-5·5] of 1073; p<0·0001) than in the routine universal testing group. Based on extrapolation, selective testing would have hypothetically missed 64·4% (95% CI 63·5-65·3; 6363 of 9879) of the estimated total of C trachomatis infections. The proportion of pharyngeal-only C trachomatis was comparable between routinely universally tested women (22·9%) and selectively tested women (20·4%), resulting in a difference of 2·5% (95% CI -0·3 to 5·3; p=0·07). When using risk factors for pharyngeal C trachomatis as testing indicators, 15 484 (79·6%) of 19 459 women would be tested to detect 398 (80·6%) of 494 infections. INTERPRETATION: No optimal testing scenario was available for pharyngeal C trachomatis, in which only a selection of high-risk women needs to be tested to find most pharyngeal C trachomatis infections. The relative low prevalence of pharyngeal-only C trachomatis (0·5%) and probably limited clinical and public health effect do not provide support for routine universal testing. FUNDING: Public Health Service South Limburg.

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.

Linked nosocomial COVID-19 outbreak in three facilities for people with intellectual and developmental disabilities due to SARS-CoV-2 variant B.1.1.519 with spike mutation T478K in the Netherlands.

BACKGROUND: Individuals with intellectual and developmental disabilities (IDD) living in congregated settings have increased risk of COVID-19 infection and mortality. Little is known about variant B.1.1.519 with spike mutation T478K, dominant in Mexico. We describe a linked SARS-CoV-2 B.1.1.519 outbreak in three IDD facilities in the Netherlands. METHODS: Following notification of the index, subsequent cases were identified through serial PCR group testing. Positive specimens were submitted for whole-genome-sequencing. Clinical information was gathered through interviews with staff members of the three facilities. RESULTS: Attack rate (AR) in clients of the index facility was 92% (23/25), total AR in clients 45% (33/73) and in staff members 24% (8/34). 55% (18/33) of client cases were asymptomatic, versus 25% (2/8) of staff members. Five client cases (15%) were hospitalized, two died (6%). Sequencing yielded the same specific B.1.1.519 genotype in all three facilities. No significant difference in median viral load was established comparing the B.1.1.519 variant with other circulating variants. The index of the linked outbreak reported no travel history or link to suspected or confirmed cases suggesting regional surveillance. Observed peak regional prevalence of B.1.1.519 during the outbreak supports this. CONCLUSION: AR, morbidity and mortality prior to control measures taking effect were high, probably related to the specific characteristics of the IDD setting and its clients. We assessed no evidence for intrinsic contributing properties of variant B.1.1.519. Our study argues for enhanced infection prevention protocols in the IDD setting, and prioritization of this group for vaccination against COVID-19.

Barriers and facilitators to infection prevention and control in Dutch residential care facilities for people with intellectual and developmental disabilities: A theory-informed qualitative study.

BACKGROUND: Care institutions are recognised to be a high-risk setting for the emergence and spread of infections and antimicrobial-resistant organisms, which stresses the importance of infection prevention and control (IPC). Accurate implementation is crucial for optimal IPC practice. Despite the wide promotion of IPC and research thereof in the hospital and nursing home setting, similar efforts are lacking in disability care settings. Therefore, this study aimed to assess perceived barriers and facilitators to IPC among professionals working at residential care facilities (RCFs) for people with intellectual and developmental disabilities (IDD), as well as to identify professional-reported recommendations to improve IPC. METHODS: This qualitative study involved semi-structured interviews (before COVID-19) with twelve professionals from five Dutch RCFs for people with IDD. An integrated theoretical approach was used to inform data collection and analysis. Thematic analysis using inductive and deductive approaches was conducted. This study followed the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines. RESULTS: Our findings revealed barriers and facilitators at the guideline, client, professional, professional interaction, professional client interaction, client interaction, organisational, community, and societal level. Six main themes covering multiple barriers and facilitators were identified: (1) guidelines' applicability to (work)setting; (2) professionals' cognitions and attitude towards IPC (related to educational background); (3) organisational support and priority; (4) educational system; (5) time availability and staff capacity; and (6) task division and change coaches. The main professional-reported recommendations were the introduction of tailored and practical IPC guidelines, structural IPC education and training among all professionals, and client participation. CONCLUSIONS: To promote IPC, multifaceted and multilevel strategies should be implemented, with a preliminary need for improvements on the guideline, professional, and organisational level. Given the heterogeneous character, i.e., different professionals, clients and care needs, there is a need for a tailored approach to implement IPC and sustain it successfully in disability care. Our findings can inform future IPC practice improvements.

Social networks and infectious diseases prevention behavior: A cross-sectional study in people aged 40 years and older.

BACKGROUND: Social networks, i.e., our in-person and online social relations, are key to lifestyle behavior and health, via mechanisms of influence and support from our relations. We assessed associations between various social network aspects and practicing behavior to prevent respiratory infectious diseases. METHODS: We analyzed baseline-data (2019) from the SaNAE-cohort on social networks and health, collected by an online questionnaire in Dutch community-dwelling people aged 40-99 years. Outcome was the number of preventive behaviors in past two months [range 0-4]. Associations between network aspects were tested using ordinal regression analyses, adjusting for confounders. RESULTS: Of 5,128 participants (mean age 63; 54% male), 94% regularly washed hands with water and soap, 55% used only paper (not cloth) handkerchiefs/tissues; 19% touched their face as little as possible; 39% kept distance from people with respiratory infectious disease symptoms; median score of behaviors was 2. Mean network size was 11 (46% family; 27% friends); six network members were contacted exclusively in-person and two exclusively via phone/internet. Participants received informational, emotional, and practical support from four, six, and two network members, respectively. Independently associated with more preventive behaviors were: 'strong relationships', i.e., large share of friends and aspects related to so called 'weak relationships', a larger share of distant living network members, higher number of members with whom there was exclusively phone/internet contact, and more network members providing informational support. Club membership and a larger share of same-aged network members were inversely associated. CONCLUSION: Friends ('strong' relationships) may play an important role in the adoption of infection-preventive behaviors. So may 'weak relationships', e.g. geographically more distant network members, who may provide informational support as via non-physical modes of contact. Further steps are to explore employment of these types of relationships when designing infectious diseases control programs aiming to promote infection-preventive behavior in middle aged-and older individuals.

COVID-19: first long-term care facility outbreak in the Netherlands following cross-border introduction from Germany, March 2020.

BACKGROUND: The Dutch province of Limburg borders the German district of Heinsberg, which had a large cluster of COVID-19 cases linked to local carnival activities before any cases were reported in the Netherlands. However, Heinsberg was not included as an area reporting local or community transmission per the national case definition at the time. In early March, two residents from a long-term care facility (LTCF) in Sittard, a Dutch town located in close vicinity to the district of Heinsberg, tested positive for COVID-19. In this study we aimed to determine whether cross-border introduction of the virus took place by analysing the LTCF outbreak in Sittard, both epidemiologically and microbiologically. METHODS: Surveys and semi-structured oral interviews were conducted with all present LTCF residents by health care workers during regular points of care for information on new or unusual signs and symptoms of disease. Both throat and nasopharyngeal swabs were taken from residents suspect of COVID-19, based on regional criteria, for the detection of SARS-CoV-2 by Real-time Polymerase Chain Reaction. Additionally, whole genome sequencing was performed using a SARS-CoV-2 specific amplicon-based Nanopore sequencing approach. Moreover, twelve random residents were sampled for possible asymptomatic infections. RESULTS: Out of 99 residents, 46 got tested for COVID-19. Out of the 46 tested residents, nineteen (41%) tested positive for COVID-19, including 3 asymptomatic residents. CT-values for asymptomatic residents seemed higher compared to symptomatic residents. Eleven samples were sequenced, along with three random samples from COVID-19 patients hospitalized in the regional hospital at the time of the LTCF outbreak. All samples were linked to COVID-19 cases from the cross-border region of Heinsberg, Germany. CONCLUSIONS: Sequencing combined with epidemiological data was able to virtually prove cross-border transmission at the start of the Dutch COVID-19 epidemic. Our results highlight the need for cross-border collaboration and adjustment of national policy to emerging region-specific needs along borders in order to establish coordinated implementation of infection control measures to limit the spread of COVID-19.