Effectiveness of educational interventions for healthcare workers on vaccination dialogue with older adults: a systematic review

BACKGROUND

Healthcare workers (HCW) significantly influence older adults' vaccine acceptance. This systematic review aimed to identify effective educational interventions for HCWs that could enhance their ability to engage in a dialogue with older adults on vaccination.

METHODS

Medline, Scopus, Cochrane library and grey literature were searched for comparative studies investigating educational interventions concerning older adult vaccinations. The search encompassed all languages and publication years. Analysis was performed on the outcomes 'vaccines offered or ordered' and 'vaccination rates'. Whenever feasible, a sub-analysis on publication year was conducted. Methodological limitations were assessed using the RoB 2 for RCTs and the GRADE checklist for non-randomized studies. Study outcomes were categorized according to the four-level Kirkpatrick model (1996) for effectiveness: reaction, learning, behaviour, and results.

RESULTS

In total, 48 studies met all inclusion criteria. Most studies included reminder systems signalling HCWs on patients due for vaccination. Other interventions included seminars, academic detailing and peer-comparison feedback. Four articles reporting on the reaction-level indicated that most HCWs had a favourable view of the intervention. Two of the six articles reporting on the learning-level observed positive changes in attitude or knowledge due to the intervention. Seventeen studies reported on the behaviour-level. An analysis on eleven out of seventeen studies focusing on vaccines 'ordered' or 'offered' outcomes suggested that tailored reminders, particularly those implemented before 2000, were the most effective. Out of 34 studies reporting on the result-level, 24 were eligible for analysis on the outcome 'vaccination rate', which showed that compared to usual care, multicomponent interventions were the most effective, followed by tailored reminders, especially those predating 2000. Nonetheless, tailored reminders often fell short compared to other interventions like standing orders or patient reminders. In both the behaviour-level and result-level 'education only' interventions frequently underperformed relative to other interventions. Seventeen out of the 27 RCTs, and seven of the 21 non-randomized studies presented a low-to-medium risk for bias in the studies' findings.

CONCLUSIONS

Tailored reminders and multicomponent interventions effectively assist HCWs in addressing vaccines with older adults. However, education-only interventions appear to be less effective compared to other interventions rates, attitude, knowledge.

Focus group study on perceptions and information needs regarding vaccines targeting the older population: a cross-country comparison in four European countries

The increasing life expectancy leads to more older adults suffering from infectious diseases. Vaccines are available against diverse infections such as influenza, pneumococcal disease, herpes zoster and tetanus. However, vaccine acceptance is crucial for optimal preventive effect. The objective of the study is to perform a cross-country analysis of the perceptions and decision-making behaviour of older adults regarding vaccinations and their information needs. Focus groups with older adults were conducted in four countries: France, Hungary, Italy and the Netherlands. Data were analysed using thematic analysis. Demographic characteristics of participants were gathered with a questionnaire. Influenza and tetanus vaccines were commonly known, as was the disease influenza. On the contrary, the awareness of the vaccines against pneumococcal disease and herpes zoster were low. Participants also expressed a need for more information on vaccines, such as possible side effects, contra-indications and duration of protection, emphasizing that information is a condition for decision-making on vaccination. General practitioners were found to be the most important in information provision on vaccines. Perceptions on vaccines, such as effectiveness, side effects and safety, as well as perceptions on infectious diseases, such as severity, susceptibility and experiencing an infectious disease, played a role in the decision-making of older adults on vaccines. More awareness of the information needs among older adults with regard to vaccines should be raised among general practitioners and other healthcare providers. This requires appropriate knowledge about the vaccines among healthcare providers as well as communication skills to meet the information needs of older adults.

Vaccines for older adults; the low-hanging fruit of disease prevention

Background

The COVID-19 pandemic highlighted the significance of vaccination for older adults (OA), however, more health benefits could be gained with vaccination against influenza, pneumococcal disease, herpes zoster and tetanus as their uptake remains rather low. As healthcare professionals (HCP) play an important role in the vaccination decision making of OA, this study identifies obstacles in vaccination communication between HCP and OA.

Methods

80 in-depth structured interviews have been conducted with HCPs in Hungary (HU), Italy (IT), the Netherlands (NL) and France (FR). Participants were general practitioners, medical specialists, public health physicians, occupational physicians, pharmacists, geriatricians, specialists elderly care and nurses. The interview included questions on HCPs’ perceptions regarding information provision to OA on vaccines. Data were analyzed cross-country, using thematic analysis.

Results

Preliminary results reveal that a factor hindering HCPs to initiate conversations with OA on vaccines was lack of time (FR, IT, HU, NL). In hospitals this was often due to (acute) clinical problems taking precedence over discussing vaccines (IT, NL). In ambulatory settings the high number of patients waiting to be seen prevented discussing vaccines with OA (HU). Moreover, HCPs sometimes forgot to discuss vaccines with OA (NL, HU, IT). Patient factors hindering the conversation of HCPs on OA vaccines were a negative attitude (IT, HU) and lack of understanding the information provided (IT, HU). Also, misinformation on vaccines (FR, HU), as well as anti-vax beliefs from patients (NL) or their relatives (FR, IT) hampered the conversation on vaccines. HCPs mentioned their need to learn communication skills to convince OA on vaccines (FR, IT, HU).

Conclusions

HCPs encounter various obstacles in communicating with OA about vaccines. Lack of time and not recognizing the opportunity to discuss vaccines are important barriers for initiating vaccine conversations.

Key messages

• Providing HCPs with communication strategies is important to support HCPs in discussing vaccines with OA.

• Reminder systems are important to help HCPs remember address vaccination.

A qualitative study of parental associations and beliefs regarding the HPV vaccination for Dutch boys

Background

Human Papillomavirus (HPV) occurs in 80% of the sexually active population and may cause certain types of cancers among men and women. Vaccination against HPV could prevent cancers associated with HPV. The Dutch National Immunization Program (NIP) only includes HPV vaccination for girls, but the HPV vaccination for boys will be implemented in 2022. Little is known about the awareness of parents and their attitudes regarding the vaccination for boys. However, these concepts might influence the intention to vaccinate one’s child. Gaining insight in these factors could lead to more effective communication strategies.

Methods

This qualitative research aimed to explore parental associations and beliefs regarding the HPV vaccination for boys. In total, 16 interviews were conducted with parents. Topics discussed were primary associations with vaccinations, associations with HPV-vaccination and information needs regarding the HPV vaccination for boys.

Results

Most parents were unaware about HPV infections in boys as well as the possibility to vaccinate their sons. Furthermore, after hearing about the vaccine parents reported uncertainties about anticipated adverse effects of the vaccine. Other themes that emerged were difficulties with the proposed age at which boys would be offered the vaccination and low risk perception of the virus.

Conclusion

Public campaigns regarding (the HPV) vaccination should improve (parental) awareness about the virus and the vaccination, and increase knowledge. Moreover, it should address concerns regarding vaccination and be transparent about decision making. For example, a rationale why HPV vaccination is needed for boys who turn 10 years and its advantage to reducing risks for boys to contract HPV related cancers should be provided.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13605-y.

Using qualitative research to develop an elaboration of the TIDieR checklist for interventions to enhance vaccination communication: short report

Background

The COVID-19 pandemic has led to an increased interest in communication with the public regarding vaccination. Our recent Cochrane qualitative evidence synthesis points to several factors that could influence the implementation and success of healthcare worker communication with older adults about vaccination. However, it is often difficult to assess whether factors identified as potentially important in qualitative studies have been considered in randomized trials because of poor trial reporting. We therefore decided to use our qualitative evidence synthesis findings to encourage better reporting of vaccination communication interventions in trials by developing an elaboration of the TIDieR (Template for Intervention Description and Replication) checklist for intervention reporting.

Methods

We examined the findings from our Cochrane qualitative evidence synthesis on healthcare workers’ perceptions of and experiences with communicating about vaccination with adults over the age of 50 years. We identified factors that could influence the implementation and uptake, and thereby the effectiveness, of vaccination communication interventions. We then drafted a list of the information elements we would need from trial reports to assess whether these factors had been considered in the development of the interventions evaluated in these trials. Finally, we compared our list of information elements to the TIDieR checklist items. We were able to align all of our information elements with the TIDieR items. However, for several of the TIDieR items, we developed a more detailed description to ensure that relevant information would be captured sufficiently in trial reports.

Results

We developed elaborations for the following TIDieR items: “Why” (item 2), “What—materials” (item 3), “Who provided” (item 5), “How” (item 6), “Where” (item 7) and “Tailoring” (item 9).

Conclusions

Both qualitative research and trials of intervention effectiveness are critical to furthering our understanding of what works, where, for whom and through which mechanisms. However, a key ingredient for developing this understanding is adequate reporting of intervention design, content and implementation in randomized trials. We hope that this elaboration of the TIDier checklist will improve reporting of interventions in trials focused on vaccine communication with older adults, and thereby enhance the usability of this research for developing future communication strategies.

The isolation room of the future: changing the perspective on isolated care

 

Antibiotic resistance is a growing problem worldwide. Several measures are taken when identified carriers of antibiotic resistant bacteria (such as MRSA) are admitted to a hospital: patients stay in an isolation room and healthcare workers have to put on personal protective equipment (PPE) before entering the isolation room. Previous research on experiences of isolated care shows that patients felt lonely, forgotten and stigmatized while healthcare personnel felt guilty for bundling their contact moments. Therefore, an innovation project has been set up to re-design the concept of an isolation room: the isolation room of the future. The isolation room of the future concentrates around providing enhancements for communication and interaction, comfort and accessibility and architecture and interior design, while taking into account the infection prevention regulations for isolation rooms in hospitals. The interior of the isolation room of the future consists of biophilic elements, including photo wallpaper, transparent walls, surfaces that mimic natural materials, and natural and dynamic light; creating a positive healing and working environment for patients, staff and visitors. Transparent walls also allow easy communication between patients and healthcare workers without the need for the PPE. Furthermore, a transfer hatch is installed to easily serve meals and drinks to the patient. A modular furniture set-up will ensure the most optimum use of space in the room. The isolation room of the future does not necessarily need to be built as a whole; specific elements can implemented depending on needs, finances and possibilities. We hope that these practical solutions might inspire healthcare facilities worldwide to re-think the concept of an isolation room to improve the experiences of people involved in isolated care. This approach is useful for a broader range of infections with pathogens that require isolation precautions, among which SARS-CoV-2.

Key messages

A change on perspective of isolated care is needed. Although based on experiences with resistant bacteria, the isolation room of the future useful for a broader range of infections with pathogens that require isolation precautions.

Healthcare workers' perceptions and experiences of communicating with people over 50 years of age about vaccination: a qualitative evidence synthesis

BACKGROUND

Infectious diseases are a major cause of illness and death among older adults. Vaccines can prevent infectious diseases, including against seasonal influenza, pneumococcal diseases, herpes zoster and COVID-19. However, the uptake of vaccination among older adults varies across settings and groups. Communication with healthcare workers can play an important role in older people's decisions to vaccinate. To support an informed decision about vaccination, healthcare workers should be able to identify the older person's knowledge gaps, needs and concerns. They should also be able to share and discuss information about the person's disease risk and disease severity; the vaccine's effectiveness and safety; and practical information about how the person can access vaccines. Therefore, healthcare workers need good communication skills and to actively keep up-to-date with the latest evidence. An understanding of their perceptions and experiences of this communication can help us train and support healthcare workers and design good communication strategies.

OBJECTIVES

To explore healthcare workers' perceptions and experiences of communicating with older adults about vaccination.

SEARCH METHODS

We searched MEDLINE, CINAHL and Scopus on 21 March 2020. We also searched Epistemonikos for related reviews, searched grey literature sources, and carried out reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored the perceptions and experiences of healthcare workers and other health system staff towards communication with adults over the age of 50 years or their informal caregivers about vaccination.

DATA COLLECTION AND ANALYSIS

We extracted data using a data extraction form designed for this review. We assessed methodological limitations using a list of predefined criteria. We extracted and assessed data regarding study authors' motivations for carrying out their study. We used a thematic synthesis approach to analyse and synthesise the evidence. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We examined each review finding to identify factors that may influence intervention implementation and we developed implications for practice.

MAIN RESULTS

We included 11 studies in our review. Most studies explored healthcare workers' views and experiences about vaccination of older adults more broadly but also mentioned communication issues specifically. All studies were from high-income countries. The studies focused on doctors, nurses, pharmacists and others working in hospitals, clinics, pharmacies and nursing homes. These healthcare workers discussed different types of vaccines, including influenza, pneumococcal and herpes zoster vaccines. The review was carried out before COVID-19 vaccines were available. We downgraded our confidence in several of the findings from high confidence to moderate, low or very low confidence. One reason for this was that some findings were based on only small amounts of data. Another reason was that the findings were based on studies from only a few countries, making us unsure about the relevance of these findings to other settings. Healthcare workers reported that older adults asked about vaccination to different extents, ranging from not asking about vaccines at all, to great demand for information (high confidence finding). When the topic of vaccination was discussed, healthcare workers described a lack of information, and presence of misinformation, fears and concerns about vaccines among older adults (moderate confidence). The ways in which healthcare workers discussed vaccines with older adults appeared to be linked to what they saw as the aim of vaccination communication. Healthcare workers differed among themselves in their perceptions of this aim and about their own roles and the roles of older adults in vaccine decisions. Some healthcare workers thought it was important to provide information but emphasised the right and responsibility of older adults to decide for themselves. Others used information to persuade and convince older adults to vaccinate in order to increase 'compliance' and 'improve' vaccination rates, and in some cases to gain financial benefits. Other healthcare workers tailored their approach to what they believed the older adult needed or wanted (moderate confidence). Healthcare workers believed that older adults' decisions could be influenced by several factors, including the nature of the healthcare worker-patient relationship, the healthcare worker's status, and the extent to which healthcare workers led by example (low confidence). Our review also identified factors that are likely to influence how communication between healthcare workers and older adults take place. These included issues tied to healthcare workers' views and experiences regarding the diseases in question and the vaccines; as well as their views and experiences of the organisational and practical implementation of vaccine services.

AUTHORS' CONCLUSIONS

There is little research focusing specifically on healthcare workers' perceptions and experiences of communication with older adults about vaccination. The studies we identified suggest that healthcare workers differed among themselves in their perceptions about the aim of this communication and about the role of older adults in vaccine decisions. Based on these findings and the other findings in our review, we have developed a set of questions or prompts that may help health system planners or programme managers when planning or implementing strategies for vaccination communication between healthcare workers and older adults.

Online respondent-driven detection for enhanced contact tracing of close-contact infectious diseases: benefits and barriers for public health practice

BACKGROUND

Online respondent-driven detection (RDD) is a novel method of case finding that can enhance contact tracing (CT). However, the advantages and challenges of RDD for CT have not yet been investigated from the perspective of public health professionals (PHPs). Therefore, it remains unclear if, and under what circumstances, PHPs are willing to apply RDD for CT.

METHODS

Between March and April 2019, we conducted semi-structured interviews with Dutch PHPs responsible for CT in practice. Questions were derived from the 'diffusion of innovations' theory. Between May and June 2019, we distributed an online questionnaire among 260 Dutch PHPs to quantify the main qualitative findings. Using different hypothetical scenarios, we assessed anticipated advantages and challenges of RDD, and PHPs' intention to apply RDD for CT.

RESULTS

Twelve interviews were held, and 70 PHPs completed the online questionnaire. A majority of questionnaire respondents (71%) had a positive intention towards using RDD for CT. Anticipated advantages of RDD were 'accommodating easy and autonomous participation in CT of index cases and contact persons', and 'reaching contact persons more efficiently'. Anticipated challenges were 'limited opportunities for PHPs to support, motivate, and coordinate the execution of CT', 'not being able to adequately convey measures to index cases and contact persons', and 'anticipated unrest among index cases and contact persons'. Circumstances under which PHPs anticipated RDD applicable for CT included index cases and contact persons being reluctant to share information directly with PHPs, digitally skilled and literate persons being involved, and large scale CT. Circumstances under which PHPs anticipated RDD less applicable for CT included severe consequences of missing information or contact persons for individual or public health, involvement of complex or impactful measures for index cases and contact persons, and a disease being perceived as severe or sensitive by index cases and their contact persons.

CONCLUSIONS

PHPs generally perceived RDD as a potentially beneficial method for public health practice, that may help overcome challenges present in traditional CT, and could be used during outbreaks of infectious diseases that spread via close contact. The circumstances under which CT is performed, appear to strongly influence PHPs' intention to use RDD for CT.

Information needs on vaccinations for older adults and the role of health care professionals in this

On behalf of all members of work package 4 from the VITAL project

Perceptions of Dutch nurses carrying methicillin-resistant Staphylococcus aureus: a qualitative study

Background

Carriers of methicillin-resistant Staphylococcus aureus (MRSA) experience a variety of personal and social consequences, despite the asymptomatic nature of carriage. Some of these consequences are inherent to the application in practice of strict infection prevention guidelines. However, the experiences of nurses carrying MRSA have not been documented. This study aimed to describe the experiences of nurses carrying MRSA to get insight into the impact of MRSA carriage on nurses in a country with a “search-and-destroy” policy for MRSA.

Methods

A qualitative study was conducted among eighteen nurses who experienced MRSA carriage and were working in healthcare organizations in the Netherlands (e.g. hospitals, nursing homes and home care). Semi-structured interviews were conducted using an interview guide. The interviews were audio tape recorded, transcribed and analyzed using thematic analysis.

Results

MRSA carriage has an impact on the life of nurses during four distinct phases: becoming aware of carrying MRSA, processing information and guidance, experiencing consequences of carriage and, when applicable, a life after eradication of MRSA. Each phase was found to be associated with negative consequences. The impact of MRSA carriage on the daily life of nurses is mostly influenced by the experience of consequences of MRSA carriage – including a ban to work with patients, eradication treatment with antibiotics, and social isolation from others – despite the asymptomatic nature of MRSA carriage itself. In addition, lack of information and guidance increased the impact of carriage.

Conclusions

This study shows nurses experience various consequences of MRSA carriage, despite the asymptomatic nature of carriage. The work ban, eradication treatment and social isolation influenced the nurses’ work-related future, personal health and social environment. The impact of carriage may be reduced by clear information and guidance, and support from others. Therefore, sufficient information and guidance needs to be given to MRSA carriers by healthcare organizations.

Example C: Using online respondent-driven detection for communicable disease control

Online respondent-driven detection (online-RDD) is a novel method of case-finding that may enhance contact tracing (CT). However, the opportunities and barriers of online-RDD for public health practice have not yet been investigated from the perspective of public health professionals (PHPs). Therefore, it is unclear what the potential strengths and limitations of online-RDD for CT are.

We conducted a sequential exploratory mixed methods research. First, we conducted semi-structured interviews with Dutch PHPs involved in CT. Questions were derived from the diffusion of innovations theory. Second, we distributed an online-questionnaire to 260 Dutch PHPs to study the main findings in a larger population. We used hypothetical scenario’s (scabies, shigella, and mumps) to elicit PHPs’ perceptions of online-RDD.

Twelve interviews were held. Response rate to the online-questionnaire was 31% (n = 70). Four themes related to characteristics of online-RDD that influenced PHPs’ intention to adopt online-RDD emerged: advantages over traditional CT, task conflicts and opportunity costs, public health risks, and situational compatibility. PHPs believed online-RDD may enhance CT through increased reach, low-key communication options, and saving time. Limitations were foreseen in the delivery of measures, supporting patients and contacts, missing information and contacts, and causing unrest. Online-RDD may be particularly applicable in situations with digitally skilled and literate target populations, low urgency, low time-pressure, and a simple perspective for action. A majority of PHPs (70%) had a positive adoption intention towards online-RDD.

PHPs perceived online-RDD as beneficial to public health practice. Further development of online-RDD should focus on facilitating opportunities for personal contact between PHPs, patients and contacts. A comparative study of ‘traditional’ CT and online-RDD could yield further insights in the potential of online-RDD for public health practice.

Understanding the perspectives of older adults and elderly regarding vaccination; a snapshot in four European countries

Prevention of infectious diseases in elderly by immunization is a prerequisite to ensuring healthy ageing. However, in order for the vaccine programs to be effective, these need to be provided by health care professionals who have up-to-date knowledge and high motivation. Furthermore, the knowledge and attitudes towards vaccination in the targeted age groups needs to be fully understood. When focusing on the information provision, it is important to know from whom or which institution older adults and elderly would like to receive and in which form.

In January 2019, an international project called the VITAL (The Vaccines and InfecTious diseases in the Ageing population) project was started, within the framework of IMI (Innovative Medicines Initiatives). One of the goals of the VITAL project is to develop strategies to educate and train health care professionals (HCPs) and to promote awareness among stakeholders involved in elderly care management.

We briefly focus on the results of studies undertaken in four European countries (Italy, France, The Netherlands and Hungary), which reveal the perspective of older adults and elderly regarding influenza, pneumococcal, herpes zoster vaccination and respiratory syncytial virus (RSV) as well as generic characteristics of the vaccines and diseases.

We will show how attitudes towards vaccination are represented in our study population and which determinants influence the decision-making process of accepting vaccination. Furthermore, we shall elaborate on how the decision-making process towards vaccination takes place and which additional information is needed.

In the second part of the session, we shall invite the audience to reflect on the findings and identify the factors they consider most important for setting up a training and education programme on vaccination.

Compact Mock Loops of the Systemic and Pulmonary Circulation for Blood Pump Testing

Mock loops are an important tool for in vitro investigations of artificial blood pumps. The simple windkessel, throttle, and atrium principle was used for the mock loop design presented. The components of the systemic and the pulmonary mock loop were designed according to calculated numerical simulation parameters. The loops offer a compact design and simple handling. For simulating biventricular assist or total artificial heart (TAH), both loops can be coupled correspondingly. The numerical simulation and the first results with the loops show very good similarity to physiological data of systemic and pulmonary circulation. The measurements of pump characteristics are significant for quantitative comparison of different pump sizes and types, or driving systems.

Pre-Clinical Evaluation of a Novel, Pneumatic, Ventricular Assist Device (Medos® HIA-VAD®) under Pathophysiological Conditions

To evaluate a new cardiac assist system, the Medos® HIA-VAD®, we studied the effects of mechanical unloading on regional and global myocardial dysfunction. As a model for the regional temporary contractile dysfunction we chose an anesthetized, open chest preparation in sheep. We occluded the diagonal coronary artery for 15 minutes and reperfused for 90 minutes. Hemodynamic parameters and wall thickening were monitored. Unloading with the 60-ml Medos® HIA-VAD® was performed either during ischemia (group II) or during reperfusion (group III). The recovery of non-uniformity indicated by post-ejection wall thickening was significantly faster (p<0.05) in both groups if compared to the non-assisted group (group I) (all groups n=4). Recovery of systolic wall thickening in the postischemic region in group I was only 76±12%, while it was 103±11% and 92±11% in groups II and III, respectively (p<0.05). In a canine model of global left ventricular failure, we occluded the left anterior descending coronary artery for 20 min, and after 5 minutes of reperfusion, the circumflex artery for 45 min (group I, n=5). After 5 min of CX occlusion in group II we performed assisted circulation for 90 min with the 10-ml (n=5) and the 25-ml (n=5) Medos® HIA-VAD®. In group I, no dog survided, in group II, all survided 4 hours of reperfusion (n=10). Lactate at the end of the experiment was 1.1±0.9 mmol/L (10-ml) and 1.1±0.2 mmol/L (25-ml) (p>0.05 vs. base line). We conclude that the Medos® HIA-VAD® is a reliable assist device that enhances myocardial recovery and allows sufficient peripheral circulation in the case of cardiogenic shock.

The intention of Dutch general practitioners to offer vaccination against pneumococcal disease, herpes zoster and pertussis to people aged 60 years and older

BACKGROUND

Increasing life expectancy results in a larger proportion of older people susceptible to vaccine preventable diseases (VPDs). In the Netherlands, influenza vaccination is routinely offered to people aged 60 years and older. Vaccination against pneumococcal disease, herpes zoster and pertussis is rarely used. These vaccines will be evaluated by the Dutch Health Council and might be routinely offered to older people in the near future. Possible expansion of the program depends partly on the willingness of general practitioners (GPs) to endorse additional vaccinations. In this study, we assessed predictors of GPs' attitude and intention to vaccinate people aged 60 years and older.

METHODS

GPs (N = 12.194) were invited to fill in an online questionnaire consisting of questions about social cognitive factors that can influence the willingness of GPs to vaccinate people aged 60 years and older, including underlying beliefs, practical considerations of adding more vaccines to the national program, demographics, and GPs' patient population characteristics. The questionnaire was filled in by 732 GPs.

RESULTS

GPs were positive both about vaccination as a preventive tool and the influenza vaccination program, but somewhat less positive about expanding the current program. Prediction analysis showed that the intention of GPs to offer additional vaccination was predicted by their attitude towards offering additional vaccination, towards vaccination as a preventive tool, towards offering vaccination during an outbreak and on GPs opinion regarding suitability to offer additional vaccination (R2 = 0.60). The attitude of GPs towards offering additional vaccination was predicted by the perceived severity of herpes zoster and pneumonia, as well as the perceived incidence of herpes zoster. Severity of diseases was ranked as important argument to recommend vaccination, followed by effectiveness and health benefits of vaccines.

CONCLUSION

Providing GPs with evidence-based information about the severity and prevalence of diseases, and effectiveness and health benefits of the vaccines, together with an active role of GPs in informing older people about vaccines, could modify the intention towards additional vaccination of people 60 years and older.

A new rotary blood pump for versatile extracorporeal circulation: the DeltaStream™

Today, rotary pumps are routinely used for extracorporeal circulation in different clinical settings and applications. A review of these applications and specific limitations in extracorporeal perfusion was performed and served as a basis for the development of the DeltaStream®. The Delta- Stream® is a miniaturized rotary blood pump of a new and unique design with an integrated drive unit. Despite its small design, the pump maintains a sufficient hydraulic capacity, which makes the DeltaStream® very flexible for intra- and perioperative applications. It also opens the field for short-term ventricular assist devices (VAD) applications or use as a component in extracorporeal life support systems (ECLS). The DeltaStream® and, specifically, its impeller design have been optimized with respect to haemolysis and nonthrombogenicity. Also, the pump facilitates an effective pulse generation in VAD applications and simulates heart action in a more physiological way than other rotary pumps or roller pumps. Hydraulic and haematological properties have been tested in vitro and in vivo. In a series of seven animal experiments in two different setups, the pump demonstrated its biocompatibility and applicability. Basic aspects of the DeltaStream® pump concept as well as important console features are presented. A summary of the final investigation of this pump is given with focus on hydraulic capabilities and results from animal studies.

Burden of four vaccine preventable diseases in older adults

BACKGROUND

Implementation of additional targeted vaccinations to prevent infectious diseases in the older adults is under discussion in different countries. When considering the added value of such preventive measures, insight into the current disease burden will assist in prioritization. The aim of this study was derive the first estimates of the disease burden in adults aged 50 years or over in the Netherlands for influenza, pertussis, pneumococcal disease and herpes zoster.

METHODS

The average annual disease burden for these four diseases in the Netherlands was calculated for the period 2010-2013 using the disability-adjusted life years (DALY) measure. Disease models and parameters were obtained from previous research. Where possible we adapted these models specifically for older adults and applied age-specific parameters derived from literature. The disease burden based on these adapted models and parameters was compared with the disease burden based on the general population models.

RESULTS

The estimated average annual disease burden was from high to low: pneumococcal disease (37,223 DALYs/year), influenza (7941 DALYs/year), herpes zoster (942 DALYs/year), and pertussis (812 DALYs/year). The adaptation of models and parameters specifically for the elderly resulted in a higher disease burden compared to the use of general population models.

CONCLUSIONS

Among older adults, the disease burden in the period 2010-2013 was highest for pneumococcal disease, mostly because of high mortality, followed by influenza. Disease burden of herpes zoster and pertussis was relatively low and consisted mostly of years lived with disability. Better information on the course of infectious diseases and long-term consequences would enable more accurate estimation of disease burden in older adults.

Attitudes of Dutch general practitioners towards vaccinating the elderly: less is more?

Background

In many European countries, vaccinations are offered to the elderly. Expanding the programme to include routine vaccination against pneumococcal disease, herpes zoster, and pertussis, for example, could reduce disease burden amongst the growing population of persons aged 50 years and older. Since most countries involve general practitioners (GPs) in the programmes, the potential success of such new vaccinations depends on the attitude of GPs towards these vaccinations. This qualitative study explores Dutch GPs’ attitudes regarding vaccination in general, and their attitudes regarding the incorporation of additional vaccines in the current Dutch influenza vaccination programme.

Methods

Interviews were held with ten Dutch GPs (five men and five women) that worked either in an academic hospital, in a practice based in a health center, or in individual practice. All interviews were recorded with a digital voice recorder and transcribed verbatim. Transcripts were analysed according to thematic analysis.

Results

GPs perceived prevention as part as their job and believed vaccination to be effective for preventing infectious diseases. However, influenza vaccination was not always perceived as effective. Doubts regarding the usefulness of additional vaccinations were identified. If additional vaccines would be offered, this should be based on scientific evidence and the severity of the infectious disease. Selection of patients for vaccination should not be based solely on age, but more on risk factors. The GP should be the central point of contact for new vaccination campaigns; however, high workload was seen as a concern. Several GPs questioned their ability to refuse to distribute the vaccinations.

Conclusions

A positive attitude towards implementing additional vaccinations is not apparent. Achieving the most health benefits seems to be the most important consideration of Dutch GPs regarding vaccinating older adults. Questions regarding the usefulness of vaccinating older adults should be taken into consideration. More research is necessary to confirm the results among a wider range of Dutch GPs.

Assessment of vaccine candidates for persons aged 50 and older: a review

BACKGROUND

The increasing life expectancy in most European countries has resulted in growth of the population 50 and older. This population is more susceptible to infectious diseases because of immunosenescence, co-morbidity and general frailty. Thus, to promote healthy aging, vaccination against vaccine-preventable-diseases could be one strategy. In addition to its possible individual benefits, vaccination may also yield social benefits, such as a lower overall cost of healthcare. Most European countries, however, offer only influenza vaccine although vaccines for pneumococcal disease, herpes zoster, pertussis, and hepatitis A are also available. Our aim is to review the knowledge of these vaccines for persons aged 50 and older and explore the arguments for expanding current vaccination programmes beyond just influenza.

METHODS

The evaluation model of Kimman et al. was used to assess herpes zoster, pneumococcal disease, pertussis and hepatitis A in terms of four domains: pathogen, vaccine, disease outcomes and cost-effectiveness. The sources were Dutch surveillance systems, seroprevalence studies and the international literature.

RESULTS

Herpes zoster, pneumococcal disease and pertussis are prevalent among persons aged 50 and older. Vaccines vary in effectiveness and have mild and self-limiting side effects. Vaccination against pneumococcal disease and pertussis causes adaptation of the responsible pathogen. For pertussis and hepatitis A, the vaccine is not registered specifically for the elderly population. Vaccination against herpes zoster and pertussis could improve quality of life, while vaccination against pneumococcal disease and hepatitis A prevents mortality. However, only vaccination against herpes zoster and pneumococcal disease appear to be cost-effective.

CONCLUSIONS

Vaccination can improve the health of the elderly population. As our review shows, however, the data are too incomplete to accurately judge its potential impact. More research is needed to determine how vaccination can most effectively improve the health of the growing population 50 years and older.

Prevalence and determinants associated with healthcare-associated infections in long-term care facilities (HALT) in the Netherlands, May to June 2010

HAIs (healthcare-associated infections) are likely to become an increasing public health problem. Therefore, a point-prevalence study called HALT (Healthcare-associated infections in long-term-care facilities) was set up by the European Centre for Disease Prevention and Control to determine the prevalence, antibiotic use and determinants associated with HAIs. In the Netherlands, 10 nursing homes (in total 1,429 elderly residents) participated in the study between May and June 2010. Risk and protective factors were determined by calculating relative risks (RRs) and performing multilevel Poisson regression. An overall infection prevalence of 2.8% was found and 3.5% of the residents used antibiotics. Residents' characteristics such as the presence of pressure wounds (RR: 2.58; 95% CI:1.04-6.39) and other wounds (RR: 5.70; 95% CI: 2.99-10.86) were risk factors for an HAI, whereas being male (RR: 0.43; 95% CI: 0.21-0.91) was protective. Nursing home characteristics, such as the percentage of shared rooms ( ≥ 2%) (RR: 0.49; 95% CI: 0.39-0.62) and percentage of incontinent residents (≥ 3%) (RR: 0.72; 95% CI: 0.61-0.85) were protective determinants in a multivariate analysis. Special attention is therefore needed for female residents and residents with pressure and other wounds for the prevention of HAIs in Dutch nursing homes.

Prevalence and determinants associated with healthcare-associated infections in long-term care facilities (HALT) in the Netherlands, May to June 2010

Binary file ES_Abstracts_Final_ECDC.txt matches

Dermatologic infections complicating epidermal growth factor receptor inhibitor (EGFRI) therapy in lung cancer patients

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Background: Epidermal growth factor receptor inhibitors (EGFRIs) have shown benefit in solid tumors including non-small cell lung cancers. Despite these benefits, dermatologic toxicities are reported to affect 75–87% of those treated. These toxicities impact quality of life, and may also have implications for dose modification and tumor response. This study investigates the prevalence of infections complicating dermatologic toxicities to EGFRIs in lung cancer patients. Methods: Retrospective chart review methods were employed to analyze 90 lung cancer patients treated in the Skin and Eye Reactions to Inhibitors of EGFR and Kinases (SERIES) clinic. Cultures, biopsies, and viral stains were analyzed for pathogens and sensitivities. Selection criteria included patients treated with cetuximab or erlotinib at the time of referral. Selection was limited to initial patients and their follow-up visits in the time frame of August 2007 to June 2008. The study was approved by the institutional review board. Results: Thirty (33.3%) of 90 lung cancer patients had evidence of infection at sites of dermatologic toxicity. Twenty three (25.5%) patients were positive for bacterial infection. Six of these 23 patients had concomitant fungal or viral infection. Twenty (22.2%) patients cultured positive for Staphylococcus aureus. Of the patients with Staphylococcus aureus infections, 2 (2.2%) had tetracycline-resistant Staphylococcus aureus, 2 (2.2%) had Methicillin-resistant Staphylocccus aureus (MRSA), and 1 (1.1%) had tetracycline-resistant MRSA. Fifteen of the 23 bacterial infections were localized to the seborrheic region. Three (3.3%) patients had viral infections alone and 4 (4.4%) had fungal infections alone. All of the infected patients were followed to clinical resolution. Conclusions: The data suggests that lung cancer patients treated with EGFRIs have a high prevalence of cutaneous infections. Most notably, bacterial infections developed at anatomical sites previously affected by dermatologic toxicities. Proper recognition and management of these infections by clinicians is critical for maintaining antineoplastic dose therapy, dose intensity, quality of life, and dermatologic health in lung cancer patients treated with EGFRIs.

[Table: see text]

Development of the MEDOS/HIA DeltaStream extracorporeal rotary blood pump

The DeltaStream blood pump has been developed for extracorporeal circulation with one focus on potential integration into simplified bypass systems (SBS). Its small size and an embedded electric motor are the basic pump properties. A variation of the impeller design has been performed to optimize hydraulic and hematologic characteristics. A simple impeller design was developed which allows flow and pressure generation for cardiopulmonary bypass applications. The option of a pulsatile flow mode for ventricular assist device applications also was demonstrated in vitro. Impeller washout holes were implemented to improve nonthrombogenicity. The pump was investigated for potential thermal hazards for blood caused by the integrated electric motor. It could be demonstrated that there is no thermal risk associated with this design. Durability tests were performed to assess the lifetime of the pump especially with regard to the incorporated polymeric seal. Seal lifetimes of up to 28 days were achieved using different blood substitutes. In animal tests using either the pump as a single device or in an SBS setup, biocompatibility, low hemolysis, and nonthrombogenicity were demonstrated. In summary, the DeltaStream pump shows great potential for different extracorporeal perfusion applications. Besides heart-lung machine and SBS applications, ventricular assist and extracorporeal membrane oxygenation up to several days also appear promising as potential applications.

On the use of neural network techniques to analyze sleep EEG data. Third communication: robustification of the classificator by applying an algorithm obtained from 9 different networks

This is the third communication on the use of neural network techniques to classify sleep stages. In our first communication we presented the algorithms and the selection of the feature space and its reduction by using evolutionary and genetic procedures. In our second communication we trained the evolutionary optimized networks on the basis of multiple subject data in context with some smoothing algorithms in analogy of Rechtschaffen and Kales (RK). In this third communication we could demonstrate that the robustness concerning individual specific features of automatically generated sleep profiles could be reasonably improved by an additional modification of the procedure used by SASCIA (Sleep Analysis System to Challenge Innovative Artificial Networks). The outputs of nine different networks that were created by the data of 9 different subjects were used simultaneously for classification. The medians of the values obtained in each output measure were selected for the allocation to a sleep stage. The fitness criteria of 16 automatically generated sleep profiles showed reasonable concordance with the expert profile. Even though in single cases the concordance between conventional RK classifications and automatically generated profiles were a few percentages lower, the average correct classification of the 12 classified subjects improved substantially, thus proving that the classifier is more robust against individuum-specific variability. Despite the fact that the expert generally employs three channels (EEG, EMG and EOG), at least to build up sleep profiles, the SASCIA system was able to produce profiles on the basis of only one EEG channel with 80% concordance and a correlation coefficient of 0.86. The feature selections were performed by genetic algorithms and the topologies of the networks were optimized by evolutionary algorithms. This algorithm will now be used for larger sample forward classification.

On the use of neural network techniques to analyse sleep EEG data. First communication: application of evolutionary and genetic algorithms to reduce the feature space and to develop classification rules

To automate sleep stage scoring, the system sleep analysis system to challenge innovative artificial networks (SASCIA) has been developed and implemented. The aims of our investigation were twofold: In addition to automatic sleep stage scoring the hypothesis was tested that the information of only 1 EEG channel (C4-A2) should be sufficient to automatically generate sleep profiles which are comparable with profiles made by sleep experts on the basis of at least 3-channel EEG (C4-A2), EOG and EMG, as EOG and EMG are seen as epiphenomena during sleep and the full information about the sleep stage should--according to our hypothesis--be available in the EEG. The main components of the SASCIA sleep analysis system are designed to meet the requirements of flexible adaptation to the interindividual differences of the sleep EEG. The core of the SASCIA sleep analysis system consists of neural networks. Supervised learning was implemented and the experts' scorings were included into the learning set and test set. The feature selections out of a large number (118) are performed by genetic algorithms and the topologies of the networks are optimized by evolutionary algorithms. Different mathematical procedures were used to evaluate and optimize the efficiency of the system. The profiles generated by SASCIA are in reasonable agreement with the sleep stages scored by experts according to RKR. The development of the system is communicated in three parts: the first communication deals with the application of the neural network techniques using evolutionary and genetic algorithms and with the selection of feature space. The second communication shows the training of these evolutionary optimized network techniques with multiple subjects and the application of context rules, while the third communication shows an improvement in the robustness by the simultaneous application of 9 different networks obtained from 9 subject types which were used in combination with context rules.

A new blood pump for cardiopulmonary bypass: the HiFlow centrifugal pump

Centrifugal blood pumps are considered to be generally superior to the traditionally used roller pumps in cardiopulmonary bypass. In our institute a new lightweight centrifugal sealless blood pump with a unique spherical thrust bearing and with a magnetic coupling was developed, the HiFlow. The small design makes the pump suitable for applications in complex devices or close to a patient. Hemolysis tests were carried out in which the BioMedicus pump BP-80 and a roller pump were used as reference. The centrifugal pump HiFlow showed the least blood trauma within the group of investigated pumps. In summary, the HiFlow pump concept with its low priming volume and limited contact surfaces shows great potential for clinical applications in cardiopulmonary bypass. Also, the possibility of using the pump as a short-term assist device with an option of a pulsatile driving mode was demonstrated.

Pre-clinical evaluation of a novel, pneumatic, ventricular assist device (Medos HIA-VAD) under pathophysiological conditions

To evaluate a new cardiac assist system, the Medos HIA-VAD, we studied the effects of mechanical unloading on regional and global myocardial dysfunction. As a model for the regional temporary contractile dysfunction we chose an anesthetized, open chest preparation in sheep. We occluded the diagonal coronary artery for 15 minutes and reperfused for 90 minutes. Hemodynamic parameters and wall thickening were monitored. Unloading with the 60-ml Medos HIA-VAD was performed either during ischemia (group II) or during reperfusion (group III). The recovery of non-uniformity indicated by post-ejection wall thickening was significantly faster (p < 0.05) in both groups if compared to the non-assisted group (group I) (all groups n = 4). Recovery of systolic wall thickening in the postischemic region in group I was only 76 +/- 12%, while it was 103 +/- 11% and 92 +/- 11% in groups II and III, respectively (p < 0.05). In a canine model of global left ventricular failure, we occluded the left anterior descending coronary artery for 20 min, and after 5 minutes of reperfusion, the circumflex artery for 45 min (group I, n = 5). After 5 min of CX occlusion in group II we performed assisted circulation for 90 min with the 10-ml (n = 5) and the 25-ml (n = 5) Medos HIA-VAD. In group I, no dog survived, in group II, all survived 4 hours of reperfusion (n = 10). Lactate at the end of the experiment was 1.1 +/- 0.9 mmol/L (10-ml, and 1.1 +/- 0.2 mmol/L (25-ml) (p > 0.05 vs. base line). We conclude that the Medos HIA-VAD is a reliable assist device that enhances myocardial recovery and allows sufficient peripheral circulation in the case of cardiogenic shock.

[Determining the effectiveness of percutaneous cava filters: experimental studies]

PURPOSE

In vitro clot-trapping capacity of 16 different caval filters should be evaluated under varying experimental conditions.

MATERIAL AND METHODS

In a flow model simulating in vivo conditions (soft latex tube, dextran solution at 37 degrees C, pulsatile flow at a mean rate of 3 1/min) the efficiency of 16 caval filters was evaluated in horizontal and vertical position by using 640 or 1280 clots/filter (8 sizes). Non-self centering filters were tested in centric and in tilted position.

RESULTS

Efficiency of optimally centered caval filters varied between 97.8 and 69.4%. The largest thrombi were captured by all optimal centered filters. A change from vertical to horizontal position of the flow model resulted in a variation of filter efficiency by about 4.8%. Efficiency of non-self centering filters decreased significantly when placed in a tilted position (mean decrease 15.5%; range 2.7%-37.7%) resulting in a deterioration of the capture rate by as much as 43.2%.

CONCLUSION

Under optimal study conditions efficiency of all evaluated caval filters was high. Tilting of caval filters resulted in a significant efficiency decrease.

Therapeutic drug monitoring for the treatment of psychiatric disorders. Clinical use and cost effectiveness

Pharmacokinetic monitoring is not routine in the treatment of psychiatric disorders, although subtherapeutic or toxic plasma concentrations of psychotropic agents can result from standard doses because of interindividual variability of drug metabolism. Therapeutic plasma concentrations have been established for several of the tricyclic antidepressants and for lithium, as well as for carbamazepine and valproic acid (valproate sodium). Despite difficulties in extrapolating from concentration-effect research, therapeutic concentrations have also been determined for some antipsychotic drugs, in particular haloperidol and clozapine. Clinicians can use therapeutic drug monitoring to optimise dosage decisions with psychotropic drugs, in order to maximise efficacy and prevent toxicity, especially when individuals are nonresponsive to treatment or vulnerable to adverse reactions with standard doses because age, disease states or drug interactions complicate therapy. Although evidence from controlled-outcome studies is unavailable, TDM-assisted psychiatric treatment is potentially useful and cost effective, particularly when applied by clinicians who are knowledgeable of pharmacokinetics and who are aware of the limitations of laboratory findings.

What physicians can do about firearm violence and prevention

The United States is experiencing an epidemic of firearm-related homicide and suicide, especially among teenagers. New epidemiological evidence on the risk of a gun in the home should lead further public policy efforts to address this major public health problem.

Design improvements of the HIA-VAD based on animal experiments

Since 1990, development of the Helmholtz-Institute at Aachen ventricular assist device (HIA-VAD) was mainly based on animal tests performed at the University of Groningen. Although various in vitro tests had been performed previously, animal testing resulted in significant improvements of the HIA-VAD with regard to hemodynamics and pump handling. The most important design improvement was a new trileaflet polyurethane valve, which was designed as a blood-pump valve with an emphasis on opening behavior and flow resistance. Excellent hydrodynamic performance and sufficient durability of this new valve were confirmed by various in vitro tests. Further design and manufacturing improvements resulted in a completely transparent pump, which can be easily deaired and optically controlled. Final pump design was evaluated during subsequent animal tests, and the results are very promising in view of an efficient cardiac support system.

In-vivo evaluation of the "HIA-VAD": a new German ventricular assist device

Helmholtz Ventricular Assist Devices (VAD) are pneumatically driven polyurethane membrane pumps with various volumes. The pumps are placed paracorporeally and connected with commercially available cannulas between the left atrium and aorta (left ventricular assist device) and/or right atrium and pulmonary artery (right ventricular assist device, bi-ventricular assist device). The pumps can be driven with a stand-alone driving system or with a Helmholtz IABP-console interface. Seventeen animal experiments (on calves) with Helmholtz VAD's were performed to evaluate experimental protocols, to optimize surgical techniques, and to improve design and manufacturing techniques. Blood chemistry and cell counts demonstrated that the tested HIA-70 produces low mechanical blood damage. In the course of the animal experiments the Helmholtz VAD's were made totally transparent, whereby they became easy to de-air, efficient, and affordable.

Compact mock loops of the systemic and pulmonary circulation for blood pump testing

Mock loops are an important tool for in vitro investigations of artificial blood pumps. The simple windkessel, throttle, and atrium principle was used for the mock loop design presented. The components of the systemic and the pulmonary mock loop were designed according to calculated numerical simulation parameters. The loops offer a compact design and simple handling. For simulating biventricular assist or total artificial heart (TAH), both loops can be coupled correspondingly. The numerical simulation and the first results with the loops show very good similarity to physiological data of systemic and pulmonary circulation. The measurements of pump characteristics are significant for quantitative comparison of different pump sizes and types, or driving systems.