Behavioural determinants shaping infection prevention and control behaviour among healthcare workers in Dutch general practices: a qualitative study reflecting on pre-, during and post-COVID-19 pandemic.

BACKGROUND: Since the Coronavirus Disease 2019 (COVID-19) pandemic, awareness of infection prevention and control (IPC) has increased in primary care settings. This study aimed to examine behavioural determinants shaping IPC behaviour pre-, during, and post-pandemic among healthcare workers (HCWs) in general practices, to inform optimised IPC in primary care. METHODS: For this qualitative study, semi-structured in-depth interviews were conducted during two study periods: (1) pre-COVID-19 pandemic: July 2019-February 2020, with 14 general practitioners (GPs) and medical assistants, and (2) during the COVID-19 pandemic: July 2022-February 2023, with 22 GPs and medical assistants. The design was informed by behaviour change theories. Data were analysed using thematic analysis. RESULTS: Main themes were: (1) risk perception and IPC awareness, (2) attitudes towards IPC and professional responsibility, (3) decision-making process and risk considerations for IPC adherence, (4) social norm and social influence in GP practice team, and (5) environmental context and resource availability in GP practice. During the pandemic, risk perception and awareness of the importance of IPC increased compared to the pre-pandemic period. A consistent belief emerged that IPC is part of professional responsibility, while needing to be balanced with other aspects of patient care. Decision-making is dependent on the individual GP and mainly influenced by risk assessments and sustainability considerations. The social context in the practice team can reinforce IPC behaviours. GP practice building and layout, and limited IPC resource and material availability were reported as main barriers. CONCLUSIONS: The theory-informed insights of this study can be used for targeted interventions to optimise IPC behaviour in general practices. Adopting multifaceted strategies to target the various determinants is recommended to sustain IPC, by implementing continuous education using tailored communication, integrating IPC in work routines and organisational workflows, refining existing IPC protocols by incorporating decision-making tools for HCWs, fostering a culture of IPC through knowledge-sharing and teamwork, and addressing GP practice physical environment and IPC resource barriers.

Cross-border differences in the prevalence and risk factors for carriage of antimicrobial resistance in children attending daycare centers: a point prevalence study in the Netherlands and Belgium.

BACKGROUND: Day care centres (DCCs) are ideal settings for drug-resistant bacteria to emerge. Prevalence numbers of faecal carriage of antimicrobial resistant bacteria in these settings are rare. We aimed to determine the prevalence of faecal antimicrobial resistant bacteria carriage in children attending DCCs and to assess and identify infection risk factors within DCCs in The Netherlands and Belgium. METHODS: A point-prevalence study was conducted in 28 Dutch (499 children) and 18 Belgian (448 children) DCCs. Stool samples were taken from the children's diapers and a questionnaire was filled in by their parents. Hygiene related to stool and toilet use, hygiene related to food, environmental contamination, hand hygiene and hygiene guidelines were assessed conform a standardized questionnaire by the infection prevention and control expert visiting the DCC. Multilevel logistical regression analyses were used to define which characteristics predicted the presence of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E), carbapenemase-producing Enterobacterales (CPE), vancomycin-resistant enterococci (VRE), and ciprofloxacin-resistant Enterobacterales (CipR-E). RESULTS: The ESBL-E prevalence was 16% (n = 71) in Belgium and 6% (n = 30) in the Netherlands. The CipR-E prevalence was 17% (n = 78) in Belgium and 8% (n = 38) in the Netherlands. Antimicrobial use (RR: 0.30; 95% CI: 0.33-0.48) and hospital admissions (RR: 0.37; 95% CI: 0.25-0.54) were lower in the Netherlands. Children travelling to Asia were at higher risk of being an ESBL-E carrier. Children using antimicrobials were at higher risk of being a CipR-E carrier. Cleaning the changing mat after each use was found as a protective factor for CipR-E carriage. CONCLUSIONS: We established a significant difference in ESBL-E and CipR-E carriage and antimicrobial use and hospital admissions between the Netherlands and Belgium among children attending DCCs. The differences between both countries should be further studied to improve the policy on anti-microbial use and hospital admissions in children.

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.

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.

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.

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.

Fluid intake and clinicopathological characteristics of bladder cancer: the West Midlands Bladder Cancer Prognosis Programme.

OBJECTIVE: Between 10 and 20% of bladder cancer patients who are diagnosed with nonmuscle-invasive bladder cancer will progress to muscle-invasive disease. Risk of progression depends on several factors at diagnosis including age, tumour stage, grade, size and number, and the presence or absence of carcinoma in situ. Fluid intake may be related to these factors. METHODS: Data of 1123 participants from the West Midlands Bladder Cancer Prognosis Programme were used. Data collection was via a semistructured questionnaire, and case report forms were used to collect clinicopathological data. Fluid intake was measured for six main categories: alcoholic fluids, hot fluids, fruit fluids, milk, fizzy drinks, and water, and converted into quintile variables. Multilevel mixed-effects linear regression was performed for every beverage category per clinicopathological variable and corrected for age, gender, and smoking status. RESULTS: Age at diagnosis was distributed differently amongst those in different total fluid intake quintiles (predicted means 71.5, 70.9, 71.5, 69.9, and 67.4, respectively) and showed a significant inverse linear trend in alcohol (P < 0.01), hot fluids (P < 0.01), and total fluids intake (P < 0.01), in nonmuscle-invasive bladder cancer patients. CONCLUSION: Our results suggest an inverse association for alcohol intake and total fluid intake with age at diagnosis. These results should be confirmed by future studies, alongside a possible (biological) mechanism that could influence tumour growth, and the effect of micturition frequency.

Total Fluid Intake and the Risk of Recurrence in Patients With Non-Muscle Invasive Bladder Cancer: A Prospective Cohort Study.

OBJECTIVES: To investigate the role of fluid intake from beverages before and after a diagnosis of bladder cancer in relation to the risk of developing bladder cancer recurrence. STUDY DESIGN: Prospective cohort study. METHODS: 716 patients with non-muscle invasive bladder cancer (NMIBC), who received transurethral resection of a primary bladder tumour (TURBT) and completed self-administrated questionnaires on usual fluid intake from beverages at time of diagnosis (over the year before diagnosis) and during follow-up (over the year after diagnosis), were included. Multivariable Cox regression was used to calculate hazard ratios and 95% confidence intervals of developing recurrent bladder cancer in relation to the intake of total fluid, total alcohol, and individual beverages. RESULTS: During 2,025 person-years of follow-up, 238 (33%) of the included 716 NMIBC patients developed one or more recurrences of bladder cancer. Total fluid intake before diagnosis was not associated with a first recurrence of bladder cancer when comparing the highest and lowest intake group (HR = 0.98, 95% C.I. 0.70-1.38, p = 0.91). Comparable results were obtained for total fluid intake pre-diagnosis and the risk of developing multiple recurrences of bladder cancer (HR = 1.01, 95% C.I. 0.87-1.19, p = 0.85). A total of 379 of the 716 patients reported on usual fluid intake within 1 year of diagnosis. No significant associations between total fluid intake 1 year after diagnosis and a first recurrence of bladder cancer were found when comparing the highest and lowest intake group (HR = 0.91; 95% C.I. 0.60-1.37, p = 0.65) or with multiple recurrences of bladder cancer (HR = 1.06; 95% C.I. 0.89-1.26, p = 0.54). In addition, total alcohol intake and individual beverages were not associated with bladder cancer recurrence. CONCLUSIONS: The results indicate that an individual's fluid intake from beverages is unlikely to have an important role in bladder cancer recurrence.

Fruit and vegetable intake and the risk of recurrence in patients with non-muscle invasive bladder cancer: a prospective cohort study.

INTRODUCTION: There is some evidence that greater consumption of fruit and vegetables decreases the risk of bladder cancer. The role of fruit and vegetables in bladder cancer recurrence is still unknown. OBJECTIVE: The role of total fruit and vegetable intake in relation to the risk of developing bladder cancer recurrence in a prospective cohort study. METHODS: 728 patients with non-muscle invasive bladder cancer (NMIBC), who completed self-administrated questionnaires on fruit and vegetable intake at time of diagnosis (over the year before diagnosis) and 1 year after diagnosis, were included. Hazard ratios and 95% confidence intervals were calculated by multivariable Cox regression for developing recurrent bladder cancer in relation to fruit and vegetable intake. RESULTS: During 2,051 person-years of follow-up [mean (SD) follow-up 3.7 (1.5) years], 241 (33.1%) of the included 728 NMIBC patients developed a recurrence of bladder cancer. The sum of total fruit and vegetables before diagnosis was not related to a first bladder cancer recurrence (HR 1.07; 95% CI 0.78-1.47, p = 0.66). No association was found between greater consumption of fruit and vegetables over the year before diagnosis and the risk of developing multiple recurrences of bladder cancer (HR 1.02; 95% CI 0.90-1.15, p = 0.78). Among the remaining 389 NMIBC patients who reported on fruit and vegetable intake 1 year after diagnosis, no association was found between greater consumption of fruit and vegetables and a first recurrence of bladder cancer (HR 0.65; 95% CI 0.42-1.01, p = 0.06) nor with multiple recurrences of bladder cancer (HR 1.00, 95% CI 0.85-1.18, p = 1.00). Similar results were obtained when investigating the association between total intakes of fruit and vegetables separately and bladder cancer recurrence. CONCLUSION: Results from this study did not indicate a protective role for total fruit and vegetables in the development of a recurrence of NMIBC.