Regional differences in HIV testing among European patients with sexually transmitted diseases: trends in the history of HIV testing and knowledge of current serostatus.

OBJECTIVES: To determine trends in (1) HIV testing and knowledge of current serostatus and (2) clinic-visits of aware HIV-infected patients and (3) to determine associates of incident HIV infection among patients with sexually transmitted disease (STD) in 15 countries participating in a European Community anonymous HIV seroprevalence survey. METHODS: Demographics, STD diagnosis, self-reported history of HIV tests and current HIV test results were collected for patients diagnosed with one of 12 pre-selected STDs. Incident HIV infections were determined among patients who reported prior HIV-negative test results. RESULTS: Between June 1990 and December 1996, 66560 STD patients were tested for HIV. Of these, 1581 (2.4%) reported a prior HIV-positive test. Of 41727 (62%) patients who reported no previous HIV test, 611 (1.4%) were HIV infected. Of 20785 (31%) patients who reported a prior HIV-negative test, 213 (1.0%) were HIV infected. Of 2467 (4%) patients without prior HIV test data available 123 (4.9%) were HIV infected. Overall, 63% of HIV-seropositive patients was aware of their HIV infection. Over time, the proportion of aware HIV-seropositive patients increased in some exposure categories in south and central Europe. Among the 11684 patients who reported dates of prior HIV-negative tests, 108 HIV infections were found. Compared with the north, HIV incidence was higher in the central region [odds ratio (OR), 1.23; 95% confidence interval (CI), 0.71-2.12] and in the south (OR, 4,39; 95% CI, 2.80-6.88) in all exposure categories except homosexual men. CONCLUSIONS: Two-thirds of patients with an STD had never been tested for HIV. Of all HIV infections found, 32% were undiagnosed, indicating missed opportunities for counselling, safe sex education and referral for treatment. HIV testing should be routinely offered to all STD patients.

Trends in gonorrhoea in nine western European countries, 1991-6. European Study Group.

OBJECTIVE: To present, describe, and assess trends in gonorrhoea in western Europe between 1991 and 1996. METHODS: A European Union concerted action was initiated in 1990 to monitor the prevalence of HIV among patients with a sexually transmitted infection in sentinel networks in western Europe. Data from this concerted action were used to assess trends in gonorrhoea between 1991 and 1996. Where possible, the trends were validated by comparing them with national laboratory reports or data from more extensive sexually transmitted infection surveillance networks. RESULTS: 7192 episodes of gonorrhoea were recorded at 38 sentinel sites in nine countries between 1991 and 1996. In most networks, there was a decline in the number of cases of gonorrhoea among heterosexual men and women. The decline was most marked in the Scandinavian countries. Decreases were also observed among men having sex with men, but in some networks--England and Wales, Netherlands, and Scotland--an increase was observed in more recent years. This increase was mainly the result of an increase in cases among the older age group (25 years and above). The trends observed in six of the sentinel networks were confirmed by trends in national laboratory reports or data from more extensive sexual transmitted infection surveillance systems. CONCLUSIONS: These data indicate that, overall, there was a decline in the number of gonorrhoea cases in western Europe between 1991 and 1996. The results, however, also indicate that in more recent years there was an increase in the number of gonorrhoea cases among men having sex with men in some countries. Further investigations are necessary to determine if this observation is due to an increase in risky sexual behaviours in this population group.

Prevalence of hepatitis A, B and C in the Flemish population.

Viral hepatitis is a serious health problem throughout the world. No recent prevalence data on hepatitis A, B and C were available for the population in Flanders, Belgium. For this reason, a sero-epidemiological study was undertaken in 1993-1994 in a sample of the general population. The purpose of this study was to obtain a clear picture of the prevalence of hepatitis A, B and C. Between April 1993 and February 1994, 4,058 blood samples were drawn and collected in 10 hospitals in Flanders. The study group was representative for the Flemish population. For hepatitis A a seroprevalence of 55.1% was found. In the non-Belgian residents the HAV prevalence was significantly higher than in Belgians (62% versus 52%; chi2 = 8.05; p = 0.005). For hepatitis B. 9.9% of the study group showed serological evidence of hepatitis B markers: 6.9% of the participants was positive for anti-HBs/anti-HBc, 0.7% appeared to be HBsAg positive and 3.5% was solely anti-HBs positive. The prevalence of HBV markers in Belgians was 6.9%, significantly lower compared to the 13.4% among non-Belgians (chi 2 = 14.05; p = 0.00018). 4055 serum samples were analysed for hepatitis C serology by second generation anti-HCV tests. Anti-HCV was detected in 0.87% of the serum samples. No statistically significant difference was found in HCV prevalnece between Belgians and non-Belgians. Results of this study should help policy makers in their decisions on the most appropriate hepatitis A and B vaccination strategy and on the most effective prevention strategy for hepatitis C.

Using Videotex in public health in Belgium.

In public health, access to information is more and more felt to be an urgent need. In this matter Videotex has shown to be a good working tool, though its utilisation in Belgium is not widespread yet. The Institute for Hygiene and Epidemiology has implemented EPITEL, a databank allowing for consultation of data on health and environment. The rationale for the choice of Videotex as a consulting tool is analysed here. Though very user-friendly, its high technicality allows for certain applications to function in real time mode, generate graphics, or even to consult an expert system, as the one used in the application on immunisations. In this way Videotex can also be a helpful tool in primary prevention, besides its data consulting function. This demonstration will present the five applications: health and travelling, health indicators, allergenic pollen, biological quality of the swimming waters at the coast, air pollution data. It shortly presents the hardware and software supporting the system, as well as a few results of a two-year experience running the system. Some shortcomings of the actual system may be highlighted, and possible evolutions might be discussed.

Effect of patient characteristics and disease manifestations on the outcome of acute otitis media at 2 months.

BACKGROUND: Optimal therapy for acute otitis media (AOM) is controversial and there is no consensus regarding which antibiotic to use, how long to administer it, or whether antibiotics are effective at all. Knowledge of the effects of patient characteristics and disease manifestations is needed to individualize treatment and to evaluate large-scale trials. METHODS: Data originated from 2251 patients with AOM, aged newborn to 15 years, who participated in a prospective primary care study in eight countries. At the initial visit, medical history, symptoms, physical findings, and treatment data were recorded. Follow-up 2 months later identified changes in treatment and outcome. RESULTS: Patients younger than 13 months were less likely to have recovered than those aged 13 months to 15 years (P = .05). Using univariate analysis for infants aged 12 months or younger, male sex, prior episodes of AOM, and serous otitis media were associated with poor outcome. For older patients, poor outcome was associated with initial history of ear tubes, prophylactic antibiotic use, ear discharge, decreased hearing, serous otitis media; and past episodes of AOM; the symptom of decreased hearing; and the finding of pus exuding from the tympanic membrane. Using multivariate analysis for infants aged 12 months or younger, a history of serous otitis media (odds ratio [OR], 2.3; 95% confidence interval [CI], 0.95-5.7), past episodes of AOM (OR, 1.9; 95% CI, 0.82-4.5), and male sex (OR, 1.7; 95% CI, 1.0-3.0) made independent contributions to poor outcome. For children aged 13 months to 15 years, significant variables included pus drainage (OR, 2.2; 95% CI, 1.5-3.3), a history of ear tubes (OR, 2.3; 95% CI, 1.5-3.6), past episodes of AOM (OR, 1.8; 95% CI, 1.3-2.34), and a history of serous otitis media (OR, 1.4; 95% CI, 1.0-1.9). CONCLUSIONS: Patient characteristics and disease manifestations are significant determinants of AOM outcome.

Pharmacoeconomics of immunisation: a review.

The effects of immunisation programmes that have existed for several decades in developed countries are demonstrated by the decrease and even eradication of smallpox, poliomyelitis, measles, mumps and hepatitis B. Cost, health policy and spontaneous evolution in the incidence of communicable diseases have a decisive influence on the use of a vaccine. Investment in vaccination policy has to be encouraged to maintain this progress made in the control of infectious diseases and to meet new challenges. Studies re-evaluating ongoing immunisation programmes are scarce. Nevertheless, it can be concluded that for vaccination against hepatitis B in professionally exposed at-risk populations, arguments for positive returns are consistent. The same holds for vaccination against S. pneumoniae and for influenza virus in the elderly. The results of the economic evaluation of revaccination against measles, when insufficient coverage exists, are inconclusive. Universal vaccination of children against Haemophilus influenzae type b (Hib) and of children of hepatitis B-positive mothers against hepatitis may require costs to be paid in order to gain extra health benefits.

Five years of sentinel surveillance of acute respiratory infections (1985-1990): the benefits of an influenza early warning system.

For the last five years, the Brussels Institute of Hygiene and Epidemiology has been involved in the surveillance of acute respiratory infections (ARI). The four indicators used (number of encounters of ARI by GP's/100 encounters, virus isolations, absenteeism and mortality) are discussed. A regression procedure is applied to the data collected by a sentinel network of general practitioners (GP's). This procedure permits the baseline to be visualized and an epidemic threshold to be determined in order to recognize early an influenza outbreak. The traditional use of flu-like illnesses as an indicator might be improved by the addition of non-specific ARI which are more precocious, especially in children. The criteria for an accurate definition of an influenza epidemic are discussed. The same mathematical model can be used for the analysis of mortality linked with an outbreak. It shows that the last epidemic in the winter 1989-1990 was responsible for about 4900 deaths directly or indirectly related to influenza.

Prevalence of drug-treated diabetes mellitus in Belgium. Results of a study with the collaboration of a network of pharmacies.

Within the framework of a European concerted action on diabetes mellitus (EURODIAB SubArea C), an epidemiological study was established in Belgium in 1990 in order to estimate the prevalence of drug-treated diabetes mellitus. An assessment was made of the sales of insulin and oral antidiabetic drugs and the average daily dose used. A sample of people with diabetes, clients of 107 pharmacies, provided the data to establish average daily doses. Those pharmacies, spread over the 9 provinces of the country, represent 2% of all private pharmacies in Belgium. Over a 2 month period each pharmacist presented a questionnaire to each client receiving an antidiabetic drug. In 1990, 164 per 10,000 inhabitants were treated with antidiabetic drugs, which means that there were approximately 163,000 drug-treated diabetics in Belgium. At the time of the survey 65% of the diabetics in the sample were 60 years or older. Overall, 38% of drug-treated diabetics took insulin, and 30% of them took only human insulin. Treatment type varied by the province where the pharmacy was located. The provinces of Hainaut and Luxembourg-Namur had a higher percentage of diabetics on oral treatment. This is the first description in Belgium of the prevalence of drug-treated diabetes and of the pattern of prescribing of these drugs.

Sero epidemiological characteristics of hepatitis C encountered in general practice in Belgium.

A study carried out between 1982 and 1984 established by exclusion diagnosis that 35% of viral hepatitis cases registered in Belgium were due to non A, non B (NANB) viruses. Recently, a new anti-hepatitis C virus (HCV) detection test was used to analyse the sera of patients in whom NANB hepatitis was diagnosed in that study. Using this new serological test for HCV, 29% of the NANB group was found to be positive for anti-HCV. In the 1982-84 study on viral hepatitis diagnosed by general practitioners, the number of clinically recognized infections was estimated at 14,700 (+/- 2,170; confidence interval at 95%) per year. By combining these data and the results of the present study, the following estimates could be calculated: HAV (7,129 +/- 1,054/year), HBV (2,426 +/- 358/year), HCV (1,470 +/- 216/year) and non-identified hepatitis viruses (3,675 +/- 543/year).

Declining trends in some sexually transmitted diseases in Belgium between 1983 and 1989.

OBJECTIVE: To examine trends in some sexually transmitted diseases in Belgium and to discuss them in the light of the European background. DESIGN: Analysis of the time trends of C trachomatis and N gonorrhoeae infections diagnosed by a network of microbiological laboratories, and of male urethritis diagnosed by a network of general practitioners. SETTING: Belgium. SUBJECTS: Reports of C trachomatis and N gonorrhoeae infections by a network of microbiological laboratories, and of male urethritis by a network of general practitioners, to the Institute of Hygiene and Epidemiology. RESULTS: Whereas an increase in the number of C trachomatis infections, more pronounced among women, was observed up to 1986, a small decrease has been observed afterwards in males. The mean number of chlamydial infections per laboratory and per year was 4.2 in 1983, 15.7 in 1986 and 13.9 in 1989. A decrease in the number of N gonorrhoeae infections, more pronounced among men, has been observed. The mean number of cases of gonorrhoea per laboratory and per year was 10.9 in 1983 and only 2.2 in 1989. The same declining trend has been observed in another surveillance programme of male urethritis, based on a network of general practitioners. The number of cases of male urethritis per 100 patient encounters went down from 0.06 in 1982-3 to 0.04 in 1988-9. CONCLUSION: The declining trend in Western Europe in incidence of gonococcal infections and of urethritis in men is also occurring in Belgium, but genital chlamydial infections remain an important public health problem.

A sentinel network of microbiological laboratories as a tool for surveillance of infectious diseases in Belgium.

In the development of a surveillance programme for infectious diseases in Belgium, a national network of microbiological laboratories has been responsible, since February 1983, for the weekly registration of certain pathogenic agents. Thus, the main epidemiological features of a selected number of infections in Belgium can be characterized.

HIV screening during pregnancy. Results of 2 attitude surveys on antenatal HIV screening in Belgium.

Two postal questionnaires were sent to Belgian gynaecologists in order to have information on their current policy of antenatal HIV screening. Of the 815 contacted, 446 (54.7%) completed the first questionnaire. 91.0% offers HIV testing in pregnancy; 49.1% to all pregnant women and 41.9% only to those with behavioural risks. Only 6.5% never offers HIV testing during pregnancy. The majority of these gynaecologists (79.8%) never had to deal with the problem of HIV-seropositivity in a pregnant woman. A second questionnaire with more detailed questions about HIV testing was sent to the identified respondents of the first survey. 237 of 340 (69.7%) responded. Of those, 48.9% perform HIV testing without informing the patient, whereas 43.4% always inform their patients before HIV testing. The majority performs the test at the first antenatal consultation (73.5%; 14.9% offers the test twice. These findings let us conclude that there is a need for recommendations concerning the policy of antenatal screening and information of patients.

[Epidemiologic aspects of infections due to Neisseria gonorrhoea in Belgium]. / Aspects épidémiologiques des infections à Neisseria gonorrhoeae en Belgique.

In the context of a surveillance programme for communicable diseases in Belgium, a network of microbiological laboratories has, since February, 1983, made weekly registrations of a number of pathogenic agents, among them, N. gonorrhoeae. Some epidemiological characteristics of N. gonorrhoeae in Belgium are discussed. Although only a portion of Belgian laboratories participate in the programme, the total of cases registered from 1983 through 1986 was 2 to 5 times greater than obtained through the notifiable diseases reporting system. More than 75% of the cases registered concerned those between 20 and 39 years of age, with a maximum for the 20-29-year age group. In 1985, 82% of the diagnoses were based on one culture alone (or one + ELISA); in 1986, this percentage was only 66%.

[Epidemiological aspects of Campylobacter infections in Belgium]. / Aspects épidémiologiques des infections à Campylobacter en Belgique

In the context of a surveillance programme for infectious diseases in Belgium, a network of microbiological laboratories, since February 1983, weekly registers the isolation of a number of pathogenic agents, among which Campylobacter. Some epidemiological characteristics of Campylobacter in Belgium are discussed. Between 54 and 58% of the isolations are reported from males. About 50% of the cases are observed in children under 5 years of age. The mean weekly number of isolations per laboratory is rising in May and remains high until October-November.

[Various sero-epidemiological characteristics of viral hepatitis in general medicine: results of a pilot survey performed in Belgium]. / Quelques caractéristiques séro-épidémiologiques des hépatites virales en médecine générale: résultats d'une enquête-pilote réalisée en Belgique.

A study was made of 110 cases of viral hepatitis diagnosed by general practitioners between 31 May 1982 and 30 June 1984. Hepatitis A was diagnosed in 53 patients, hepatitis B in 18 patients, hepatitis of both types A and B in one patient, and--by exclusion--hepatitis non-A non-B in 38 patients. Hepatitis A appears to be generally acquired by contact with infected persons or by travelling in endemic regions. In more than 50% of the hepatitis B cases, a hospital stay and/or ambulatory treatment were mentioned. All patients with hepatitis A became negative for anti-HA/IgM within 9 months after the diagnosis. 30% of the patients with hepatitis B remained positive for HBs Ag 9 months after diagnosis.

Tool for validation of the network of sentinel general practitioners in the Belgian health care system.

Morbidity registration by a network of sentinel general practitioners (SGPs) in Belgium raises a number of problems related to possible biases in the network procedure, such as unequal geographical distribution, non-participation of a segment of the target population of practitioners and difficulties in the estimation of the denominator population at risk for the health problems under study. Through the application of two hierarchical clustering procedures, the initial number of 43 districts in the country has been reduced to 15 homogeneous district clusters. These represent the new geographical framework from which the geographical spread of the network is checked. This network is subsequently corrected for such socio-demographic parameters as age, sex and occupation in order to match more closely the total population of Belgian general practitioners (GPs). The population covered by the network is estimated on the basis of the annual number of patient contacts. Application of the described procedures should result in a network allowing valid estimations for a number of health issues as seen by Belgian GPs.

The national prevalence survey of nosocomial infections in Belgium, 1984.

A national one-day prevalence survey of nosocomial infections was carried out in March 1984 in 106 Belgian acute-care hospitals involving 8723 patients of whom 6130 had undergone surgery. Three infections were studied: surgical wound infection, bacteraemia and urinary-tract infection. One or more of these three infections was recorded in 9.3% of all patients and in 11.8% of surgical patients. Prevalences increased with increasing duration of hospital stay and with higher ages, but the association of HAI with age was no longer significant after correction for duration of hospital stay. Prevalences varied considerably in different specialties. After adjustment for age and duration of stay, there was no association between perioperative antibiotic prophylaxis and the prevalence of the infections studied, but bias due to selection of higher risk patients in the antibiotic group was probable. Larger hospitals had a higher overall prevalence, but populations differed according to the size of the hospital. Bacteraemia was strongly associated with the presence of an intravenous catheter, and urinary-tract infection with a urinary catheter.