The HIV prevalence among pregnant women in the Amsterdam region (1988–1991)

The objective of the study was to monitor the HIV prevalence in the years 1988–1991 among pregnant women in the Amsterdam region, visitors to an abortion clinic and 3 outpatient infertility clinics. All women attending these clinics were asked to participate in the study on a voluntary basis and were tested with informed consent. The women were questioned about risk-bearing behaviour of themselves and their sexual partner(s). In the period 1988–1991, of the 23,827 eligible pregnant women, 22,165 women participated (93.0%). Twenty-seven women were found to be positive for HIV antibodies (0.12%, 95% CI: 0.08%–0.17%), of whom twenty belonged to a known HIV risk group or had a partner who belonged to one of these groups and 7 women had no known HIV risk. Seventeen of the 27 women had a foreign nationality. The annual HIV prevalence among pregnant women was: 1988: 0.28%; 1989: 0.10%; 1990: 0.10%; 1991: 0.11%. In the years 1990 and 1991, of the 1,128 eligible women visiting the abortion clinic 953 (84.5%) were tested. Eleven women were HIV-seropositive (1.15%, 95% CI: 0.6%–2.0%), of whom 9 were from an AIDS endemic region, 1 woman had a partner from this region and 1 woman had no known HIV risk. Four African women had HIV-2 antibodies. At the 3 outpatient infertility clinics 1 woman was found to be HIV-positive (0.13%; 95% CI: 0.02–0.9). She had no other risk than a partner from an AIDS endemic area. In the Amsterdam region there was a steady and low HIV prevalence (0.1%) among pregnant women through the years 1988–1991. The prevalence in the abortion clinic was ten times higher. The program was able to detect possible high risk groups within the population. Migration and travelling can play an important role in the spread of HIV in the general heterosexual population.     

The risk of disseminated Bacille Calmette-Guerin (BCG) disease in HIV-infected children

OBJECTIVES: Bacille Calmette-Guerin (BCG), a live attenuated Mycobacterium bovis vaccine, poses a risk to human immunodeficiency virus (HIV)-infected children; this risk has not been well quantified. We estimate the risk of disseminated BCG disease in HIV-infected children in a setting highly endemic for tuberculosis and HIV. DESIGN AND METHODS: We conducted a prospective hospital-based surveillance study in the Western Cape Province, South Africa. Clinical and laboratory-confirmed cases of disseminated BCG disease in children<1 year of age from January 2002 to December 2004 at a referral hospital were used as numerator data. Denominator data for calculations of disseminated BCG risk were obtained through estimating the total number of HIV-infected infants receiving BCG based on the known vaccination coverage in the study setting, combined with population data on the total number of children<1 year of age, the known HIV prevalence amongst women attending public antenatal care facilities and different scenarios (5-15%) for the rate of vertical HIV transmission. RESULTS: Nine cases of disseminated BCG disease were identified over the study period, seven of these were in HIV-infected infants. The estimated risk for HIV-infected infants to develop disseminated BCG disease, given a 95% BCG coverage and an HIV prevalence of 12.4-15.4% amongst women, were as follows for different scenarios of vertical HIV transmission: 329-417/100,000 vaccinees (assuming 5% vertical HIV transmission), 164-208/100,000 vaccinees (assuming 10% vertical HIV transmission) and 110-139/100,000 vaccinees (assuming 15% vertical HIV transmission). CONCLUSIONS: The risk of disseminated BCG disease is increased several hundred fold in HIV-infected infants compared to the documented risk in HIV-uninfected infants. Data on the protective effect of BCG in HIV-exposed and infected children is lacking. Population- and hospital-based surveillance is vitally important to more accurately estimate the safety and benefits of BCG in HIV-exposed and infected infants.     

Massive rectal blood loss after colonoscopy

A 70-year-old man presented with acute lower gastrointestinal bleeding. A colonoscopy performed one and a half months prior had revealed diverticulosis in the sigmoid colon; a small polyp located 10 cm from the anal margin had been removed at that time. The presenting patient was haemodynamically unstable and there was a significant amount of rectal blood loss. Gastroscopy revealed no abnormalities. During angiography, the patient died as a result of haemorrhagic shock. The post-mortem examination revealed a rectal perforation, which had most likely resulted from the polypectomy, and a secondary haematoma located between the common iliac artery and the rectum. The source of the gastrointestinal bleeding was the rupture of the haematoma directly into the rectal perforation. Colonoscopy is a relatively safe procedure; however, this case illustrates that potentially lethal complications from colonoscopy can be expressed, even after a few months.     

Incidence of acute hepatitis B in different ethnic groups in a low-endemic country, 1992-2009: Increased risk in second generation migrants

Background

The Netherlands is a low-incidence country for acute hepatitis B (HBV) infection (1.2/100,000 in 2010), where it is typically acquired in adulthood through injecting drug use or homosexual exposure. Recently, the number of heterosexually acquired acute infections in the Netherlands has increased. Ethnicity may be a risk factor. We describe trends in the incidence of acute HBV among heterosexual adults in ethnic groups in Amsterdam from 1992 to 2009 and discuss future control of HBV in the Netherlands.

Methods

We studied all cases of acute HBV acquired in heterosexuals aged ≥15 years in the Amsterdam region (1992–2009, n = 238) by ethnic group. Incidence rates were estimated as the average number of cases per 100,000 per year. Using Poisson regression, we calculated univariable and multivariable incidence rate ratios (IRR) by ethnic group over calendar year, by age and gender.

Results

The incidence in first generation migrants from HBV-endemic countries (FGM) was 4.1/100,000 showing no trend over time. Since 1999, incidence in Dutch-born cases in Amsterdam has increased by 13% annually from 0.2/100,000 in 1999 to 2.1/100,000 in 2009 (annual IRR 1.13, 95% CI:1.0–1.22). From 2004 to 2009, the incidence in native Dutch/Western in Amsterdam was 1.6/100,000 (reference for IRR), in FGM was 4.3/100,000 (IRR of 2.7, 95% CI:1.8–4.2) and in Dutch-born second generation migrants (SGM) was 3.7/100,000 (IRR:2.4, 95% CI:1.2–4.7).

Conclusion

Incidence of acute hepatitis B in Amsterdam in FGM and SGM is higher than in the native Dutch population. Low-endemic countries with migrant populations from HBV-endemic areas should consider offering screening and vaccination to both FGM and SGM.     

"Anti-smoking data are exaggerated" versus "the data are clear and indisputable": examining letters to the editor about tobacco

Media advocacy plays a unique role in tobacco control policy development. Letters to the editor in particular are an interesting form of media advocacy because they reflect community sentiment regarding the policy agenda and provide insight into the public debate. The authors used ethnographic context analysis to examine the techniques used by writers of 262 tobacco-related letters to the editor published in 61 newspapers across Missouri over a 2-year period when tobacco tax and smoke-free indoor air initiatives were occurring across the state. The authors found that pro-tobacco control letter writers often used didactic strategies, citing numbers and reports, to convey information and presented their training or experience as a health professional (e.g., M.D., Ph.D.) to add legitimacy to their arguments. Anti-tobacco control letter writers, in contrast, used narrative strategies to support their stance, claimed authority as a smoker or small business owner to legitimize their claims by relating to the audience, and used collectivity to capture the attention of policymakers. These results present the importance of strategic media advocacy in tobacco control. Tobacco control advocates should increase their use of narrative strategies and collectivity in order to better connect with the public and policymakers.     

Understanding and improving communication and decision-making in palliative care for Turkish and Moroccan immigrants: a multiperspective study

Objective. The aim of this study is to explore how communication and decision-making in palliative care among Turkish and Moroccan patients is influenced by different styles of care management between Turkish and Moroccan families and Dutch professional care providers. Problems as well as solutions for these problems are highlighted. Design. A qualitative design was used, totally interviewing 83 people (6 patients, 30 relatives and 47 care providers) covering 33 cases of incurable cancer patients receiving palliative care. Data were analysed thematically and contextually. Results. The analysis reveals that problems in decision-making are partly related to differences in ethnic-cultural views on 'good care' at the end of life: Dutch palliative care providers prefer to focus on quality of life rather than on prolonging life, while Turkish and Moroccan families tend to insist on cure. Another barrier is caused by conflicting views on the role of the 'care management group': Dutch care providers see the patient as their primary discussion partner, while in Turkish and Moroccan families, relatives play a major part in the communication and decision-making. Moreover, the family's insistence on cure often leads to the inclusion of additional care providers in communication, thus complicating joint decision-making. Conclusion. Care providers need to understand that for Turkish and Moroccan patients, decision-making is seldom a matter of one-to-one communication. Next to acknowledging these patients' different cultural backgrounds, they must also recognise that the families of these patients often function as care management groups, with an 'equal' say in communication and decision-making. In addition, professionals should optimise communication within their own professional care management group.     

Acceptance of vaccination during pregnancy: experience with 2009 influenza A (H1N1) in the Netherlands

Objectives

In 2009, the Dutch government advised pregnant women to get vaccinated against influenza A (H1N1). A study was set up to gain insight into vaccination coverage and reasons why pregnant women seek vaccination or not.

Methods

We invited 14,529 pregnant women to complete an internet survey on vaccination during pregnancy in general and against 2009 influenza A (H1N1). Differences in background characteristics between unvaccinated and vaccinated women were investigated. Prediction analyses were carried out to determine which survey statement had the greatest impact on vaccination status or intention to get vaccinated during pregnancy.

Results

Of the 2993 included respondents, 63% reported to be vaccinated against 2009 influenza A (H1N1). Vaccination coverage was higher among older birth cohorts, women who had been pregnant before, women with underlying medical conditions, and women who reported no defined ‘life philosophy’. Protection of the child (after birth), the government's advice and possible harmful effects of the vaccine for the unborn child had the greatest predictive value for vaccination status. With regards vaccination during future pregnancies, 39% had a positive intention to obtain vaccination and 45% were neutral. The government's advice was the strongest predictor for intention. Furthermore, women expressed concern over lack of sufficient knowledge about vaccine safety.

Conclusions

A considerable number of pregnant women in the Netherlands reported to be vaccinated against 2009 influenza A (H1N1). The challenge for the government in the future will be to provide pregnant women and health care professionals with sufficient and clear information about disease severity and the benefits and safety of vaccination.     

Access to Health Care for Undocumented Migrant Children and Pregnant Women: The Paradox Between Values and Attitudes of Health Care Professionals

Access to health care for undocumented migrant children and pregnant women confronts human rights and professional values with political and institutional regulations that limit services. In order to understand how health care professionals deal with these diverging mandates, we assessed their attitudes toward providing care to this population. Clinicians, administrators, and support staff (n = 1,048) in hospitals and primary care centers of a large multiethnic city responded to an online survey about attitudes toward access to health care services. Analysis examined the role of personal and institutional correlates of these attitudes. Foreign-born respondents and those in primary care centers were more likely to assess the present access to care as a serious problem, and to endorse broad or full access to services, primarily based on human rights reasons. Clinicians were more likely than support staff to endorse full or broad access to health care services. Respondents who approved of restricted or no access also endorsed health as a basic human right (61.1%) and child development as a priority (68.6%). A wide gap separates attitudes toward entitlement to health care and the endorsement of principles stemming from human rights and the best interest of the child. Case-based discussions with professionals facing value dilemmas and training on children’s rights are needed to promote equitable practices and advocacy against regulations limiting services.