Gé Donker

EMERGENCE AND EPIDEMIC OCCURRENCE OF ENTEROVIRUS 68 RESPIRATORY INFECTIONS IN THE NETHERLANDS IN 2010

Following an increase in detection of enterovirus 68 (EV68) in community surveillance of respiratory infections in The Netherlands in 2010, epidemiological and virological analyses were performed to investigate the possible public health impact of EV68 infections. We retrospectively tested specimens collected from acute respiratory infections surveillance and through three children cohort studies conducted in The Netherlands from 1994 through 2010. A total of 71 of 13,310 (0.5%) specimens were positive for EV68, of which 67 (94%) were from symptomatic persons. Twenty-four (34%) of the EV68 positive specimens were collected during 2010. EV68-positive patients with respiratory symptoms showed significantly more dyspnea, cough and bronchitis than EV68-negative patients with respiratory symptoms. Phylogenetic analysis showed an increased VP1 gene diversity in 2010, suggesting that the increased number of EV68 detections in 2010 reflects a real epidemic. Clinical laboratories should consider enterovirus diagnostics in the differential diagnosis of patients presenting with respiratory symptoms.

Internet-based monitoring of influenza-like illness in the general population: Experience of five influenza seasons in the Netherlands

Like in most other countries, influenza surveillance in The Netherlands is based upon influenza-like illness (ILI) consultations reported by sentinel general practitioners (GP). In addition, an internet-based monitoring of ILI in the general population started in 2003/2004 (Great Influenza Survey (GIS)). We compared GIS results over 5 influenza seasons with results from the GP system. Weekly ILI incidence from GIS correlated well with ILI incidence from the GP system the same week and even better 1 week later. This suggests that GIS is useful for early detection of trends in influenza activity. However, two important vulnerable groups, children and the elderly, are clearly underrepresented in the GIS. Furthermore, virological confirmation is lacking in the GIS. So, GIS can be a useful addition to the GP system, especially when representativeness can be improved and when participation remains at the current high level.

Transitions between care settings at the end of life in the Netherlands: results from a nationwide study.

Multiple transitions between care settings in the last phase of life could jeopardize continuity of care and overall end-of-life patient care. Using a mortality follow-back study, we examined the nature and prevalence of transitions between Dutch care settings in the last 3 months of life, and identified potential characteristics associated with them. During the 2-year study period, 690 registered patients died ‘totally expectedly and non-suddenly’. These made 709 transitions in the last 3 months, which involved a hospital two times out of three, and covered 43 distinct care trajectories. The most frequent trajectory was home-to-hospital (48%). Forty-six percent experienced one or more transitions in their last month of life. Male gender, multi-morbidities, and absence of GP awareness of a patient’s wish for place of death were associated with having a transition in the last 30 days of life; age of ≤85 years, having an infection and the absence of a palliative-centred treatment goal were associated with terminal hospitalization for ≥7 days. Although the majority of the ‘totally expected and non-sudden’ deaths occurred at home, transitions to hospitals were relatively frequent. To minimize abrupt or frequent transitions just before death, timely recognition of the palliative phase of dying is important.

Continued seasonal circulation of enterovirus D68 in the Netherlands, 2011-2014.

Enterovirus D68 (EV-D68) continued to circulate in a seasonal pattern in the Netherlands, after the outbreak in 2010. Outpatient EV-D68 cases, mainly in the under 20 and 50–59 years age groups, presented with relatively mild respiratory disease. Hospital-based enterovirus surveillance identified more severe cases, mainly in children under 10 years of age. Dutch partial VP1 genomic region sequences from 2012 through 2014 were distributed over three sublineages similar to EV-D68 from the outbreak in the US in 2014.

End-of-Life Decisions: A Cross-National Study of Treatment Preference Discussions and Surrogate Decision-Maker Appointments

Background Making treatment decisions in anticipation of possible future incapacity is an important part of patient participation in end-of-life decision-making. This study estimates and compares the prevalence of GP-patient end-of-life treatment discussions and patients’ appointment of surrogate decision-makers in Italy, Spain, Belgium and the Netherlands and examines associated factors. Methods A cross-sectional, retrospective survey was conducted with representative GP networks in four countries. GPs recorded the health and care characteristics in the last three months of life of 4,396 patients who died non-suddenly. Prevalences were estimated and logistic regressions were used to examine between country differences and country-specific associated patient and care factors. Results GP-patient discussion of treatment preferences occurred for 10%, 7%, 25% and 47% of Italian, Spanish, Belgian and of Dutch patients respectively. Furthermore, 6%, 5%, 16% and 29% of Italian, Spanish, Belgian and Dutch patients had a surrogate decision-maker. Despite some country-specific differences, previous GP-patient discussion of primary diagnosis, more frequent GP contact, GP provision of palliative care, the importance of palliative care as a treatment aim and place of death were positively associated with preference discussions or surrogate appointments. A diagnosis of dementia was negatively associated with preference discussions and surrogate appointments. Conclusions The study revealed a higher prevalence of treatment preference discussions and surrogate appointments in the two northern compared to the two southern European countries. Factors associated with preference discussions and surrogate appointments suggest that delaying diagnosis discussions impedes anticipatory planning, whereas early preference discussions, particularly for dementia patients, and the provision of palliative care encourage participation.

End-of-Life Care and Circumstances of Death in Patients Dying As a Result of Cancer in Belgium and the Netherlands: A Retrospective Comparative Study

PURPOSE To examine and compare end-of-life care in patients with cancer dying in Belgium and the Netherlands. PATIENTS AND METHODS A mortality follow-back study was undertaken in 2008 via representative nationwide sentinel networks of general practitioners (GPs) in Belgium and the Netherlands. By using similar standardized procedures, GPs reported on aspects of end-of-life care and the circumstances of nonsudden death of patients with cancer in their practice. RESULTS Of the 422 reported patients with cancer, most resided at home during the last year of life (Belgium, 91%; the Netherlands, 95%). Death occurred at home in 34% (Belgium) and 61% (the Netherlands) and in the hospital in 29% (Belgium) and 19% (the Netherlands). In the last month of life, end-of-life issues were more often discussed in the Netherlands (88%) than in Belgium (68%). In both countries, physical problems were discussed most often (Belgium, 49%; the Netherlands, 78%) and spiritual issues least often (Belgium, 20%; the Netherlands, 32%). Certain end-of-life treatment preferences were known for 43% (Belgium) and 67% (the Netherlands) of patients. In the last week of life, treatment was most often focused on palliation (Belgium, 94%; the Netherlands, 91%). Physical distress was reported in 84% (Belgium) and 76% (the Netherlands) of patients and psychological distress in 59% and 36%. Most distressing was lack of energy (Belgium, 73%; the Netherlands, 71%) and lack of appetite (Belgium, 61%; the Netherlands, 53%). Two thirds of patients were bedridden (Belgium, 67%; the Netherlands, 69%). CONCLUSION Although place of death and communication about end-of-life issues differ substantially, a palliative treatment goal is adopted for the vast majority of patients in both countries. However, GPs reported that the majority of patients experienced symptom distress at the end of life, which suggests important challenges remain for improving end-of-life care.

Actual and preferred place of death of home-dwelling patients in four European countries: making sense of quality indicators.

Background Dying at home and dying at the preferred place of death are advocated to be desirable outcomes of palliative care. More insight is needed in their usefulness as quality indicators. Our objective is to describe whether “the percentage of patients dying at home” and “the percentage of patients who died in their place of preference” are feasible and informative quality indicators. Methods and Findings A mortality follow-back study was conducted, based on data recorded by representative GP networks regarding home-dwelling patients who died non-suddenly in Belgium (n = 1036), the Netherlands (n = 512), Italy (n = 1639) or Spain (n = 565). “The percentage of patients dying at home” ranged between 35.3% (Belgium) and 50.6% (the Netherlands) in the four countries, while “the percentage of patients dying at their preferred place of death” ranged between 67.8% (Italy) and 86.0% (Spain). Both indicators were strongly associated with palliative care provision by the GP (odds ratios of 1.55–13.23 and 2.30–6.63, respectively). The quality indicator concerning the preferred place of death offers a broader view than the indicator concerning home deaths, as it takes into account all preferences met in all locations. However, GPs did not know the preferences for place of death in 39.6% (the Netherlands) to 70.3% (Italy), whereas the actual place of death was known in almost all cases. Conclusion GPs know their patients’ actual place of death, making the percentage of home deaths a feasible indicator for collection by GPs. However, patients’ preferred place of death was often unknown to the GP. We therefore recommend using information from relatives as long as information from GPs on the preferred place of death is lacking. Timely communication about the place where patients want to be cared for at the end of life remains a challenge for GPs.

Long time trends in influenza-like illness and associated determinants in The Netherlands

We analysed long-term epidemiological trends in influenza-like illness (ILI) in The Netherlands and used an ecological analysis to estimate its relationship with age, influenza vaccination, and virological aspects. This study used data from weekly ILI consultation reports from sentinel general practitioners (1986/1987 to 2006/2007), virological data from sentinel ILI patients (1992/1993 to 2006/2007), and data for influenza vaccine uptake (1991-2005). The incidence of ILI consultations, although varying during the study period, was estimated to decrease in the total population by 12.2/10 000 persons each season (95% CI 8.6-15.9). Uptake of influenza vaccination in people aged > or = 65 years (elderly) increased from 28% in 1991 to >70% since 1997. ILI incidence in the elderly declined by 1.7/10 000 persons (P=0.05) per percentage vaccine uptake per season. The decline in ILI incidence over the last 20 years could be related to the increased vaccine uptake. However, insufficient data were present to assess the impact of other potential contributing factors, such as diminished fitness of influenza viruses and changes in consulting behaviour.

Antibiotic susceptibility of unselected uropathogenic Escherichia coli from female Dutch general practice patients: a comparison of two surveys with a 5 year interval

OBJECTIVES To optimize empirical treatment of urinary tract infections (UTIs), regular evaluation of the antibiotic susceptibility of the most common uropathogen, Escherichia coli, is necessary. We compared the antibiotic prescription rate for UTIs in women and the E. coli antibiotic susceptibility results, including the prevalence of extended-spectrum β-lactamase (ESBL)-producing strains, in 2009 with data collected 5 years earlier. PATIENTS AND METHODS Urinary samples from female patients with symptoms of uncomplicated UTI in 42 general practices were collected over a 6 month period. Uropathogens were identified and the antibiotic susceptibility of E. coli was determined. RESULTS We analysed 970 urine cultures, of which 785 (81%) were considered positive (≥ 10(3) cfu/mL). E. coli accounted for 72% of the isolates. ESBLs showed an increase between the two surveys (0.1% versus 1%; P < 0.001), while no difference in antibiotic susceptibility to the commonly used antimicrobial agents for UTIs was observed. A significantly lower susceptibility rate to co-amoxiclav was observed in the eastern region of the Netherlands, as compared with the northern region (80% versus 92%; P <  0.05). Consistent with national guidelines, the prescription rate of trimethoprim decreased over time (19% versus 5%; P  < 0.05) whereas nitrofurantoin and fosfomycin rates showed an increase (58% versus 66% and 0% versus 6% respectively, both P  < 0.05). CONCLUSIONS Over a 5 year period, the antibiotic susceptibility of uropathogenic E. coli did not change in female patients with uncomplicated UTI in the Netherlands, but ESBL prevalence increased. With respect to the prescription of antimicrobial agents, compliance with national UTI guidelines was good.

Macrolide Resistance Determination and Molecular Typing of Mycoplasma pneumoniae in Respiratory Specimens Collected between 1997 and 2008 in The Netherlands

ABSTRACT An important role in the treatment regimens for Mycoplasma pneumoniae infections is played by macrolide (ML) antibiotics. In the past few years, however, a steady increase has been detected in the worldwide prevalence of ML-resistant (MLr) M. pneumoniae strains. It is obvious that this increase necessitates a continuous monitoring of MLr and, when detected, modification of antibiotic treatment modalities. Previously, we developed a pyrosequencing-based assay system for the genetic determination of MLr as well as molecular typing of M. pneumoniae. In this study, the sensitivity of this system was improved by the inclusion of a nested-PCR protocol. The modified system was applied to 114 M. pneumoniae-positive specimens that were obtained from a collection of 4,390 samples from patients with acute respiratory tract infections. These samples were collected between 1997 and 2008 in The Netherlands. The pyrosequencing system produced reliable data in 86% of the specimens that contained >500 M. pneumoniae genome copies/ml of patient sample. Each of these samples contained DNA of the ML-sensitive genotype. While 43% of the samples were found to harbor the M. pneumoniae subtype 1 genotype, 57% contained the subtype 2 genotype. We conclude that the pyrosequencing-based assay system is a useful tool for MLr determination and molecular typing of M. pneumoniae in patient samples. MLr-associated M. pneumoniae genotypes, however, were not found in the current study population.