Following an outbreak of Andes hantavirus (ANDV) infections on a cruise ship in May 2026, a healthcare worker not directly involved in caring for an imported ANDV case in the Netherlands had a single low-positive ANDV PCR result. The healthcare worker remained asymptomatic, showed no seroconversion, and all subsequent samples tested negative. We describe a retrospective investigation, including detailed reconstruction of potential transmission routes. Our finding may indicate that asymptomatic ANDV infections with low-level viraemia can occur after indirect exposure.

The Netherlands has one of the lowest prevalences of methicillin-resistant Staphylococcus aureus (MRSA) in Europe due to its stringent Search and Destroy policy, including isolation of suspected carriers. Unexpected MRSA detection in non-isolated patients triggers contact tracing and screening of exposed patients and healthcare workers (HCWs). Given evolving epidemiology and healthcare practices, periodic re-evaluation of control measures is essential to sustain low prevalence while minimizing burden. This retrospective study at a Dutch tertiary hospital (2022–2024) assessed (1) diagnostic accuracy and utility of rapid MRSA PCR using Copan eSwab and Xpert MRSA NxG (Cepheid, GeneXpert); (2) proportion of unexpected MRSA among newly detected carriers; (3) transmission risk after unprotected MRSA exposure; (4) implications for optimizing screening and isolation. Data were extracted from electronic patient and laboratory records. MRSA culture and PCR results (throat, nose, rectum combined) were compared and stratified by screening indication. Among 1939 MRSA screenings, 89 (4.6

This study aims to analyse the impact of a newly developed infection prevention and control (IPC) Virtual Reality (VR)-module on medical students’ IPC knowledge, attitudes and practices. Additionally, the impact of the module on students’ and healthcare professionals’ (HCPs) confidence regarding IPC decision-making and their insight into consequences of IPC decisions were analysed. The IPC VR-module was developed using a cyclical design process consisting of a prototype, first and final version. Knowledge, attitudes and practices (KAP) regarding IPC were compared between two groups of medical students. The VR-module was added to the IPC program for the VR group. After completion of the program, students of both groups were asked to complete an online questionnaire. Scores were summated for each subscale of the KAP, a Mann-Whitney U test was performed to compare scores between groups. Student and HCP responses to VR-specific questions were dichotomized and a chi-square test was used to compare responses to different versions of the module. Students who completed the VR-module (n = 34) scored higher on IPC knowledge questions (score 8 / 10), than those who followed the regular program (n = 58; score 7/10; p = 0.003). For the final version, the added value of the VR-module in the program was recognized by 95

In pandemic preparedness and response, a Functional Exercise (FX) is used to simulate a situation as close to a real-life event as possible without the deployment of resources. Participants are drawn from public health emergency operations centres, and work through a scenario script to test possible responses to a novel pathogen outbreak. This paper summarises the role of system dynamics modelling in the design and implementation of a functional exercise, which involved the Dutch and German national public health institutes in March 2023. The findings confirm the value of the system dynamics method in integrating disease and hospital models, and also highlights how well the method aligns with modern software development processes. The paper concludes with a discussion of what worked well, and presents areas for future enhancements of management flight simulators to support functional exercises. (c) 2024 The Author(s). System Dynamics Review published by John Wiley & Sons Ltd on behalf of System Dynamics Society.

Abstract Background Generating insights into resource demands during outbreaks is an important aspect of pandemic preparedness. The EU PANDEM-2 project used resource modelling to explore the demand profile for key resources during pandemic scenarios. This review aimed to identify public health and healthcare resources needed to respond to pandemic threats and the ranges of parameter values on the use of these resources for pandemic influenza (including the novel influenza A(H1N1)pdm09 pandemic) and the COVID-19 pandemic, to support modelling activities. Methods We conducted a systematic literature review and searched Embase and Medline databases (1995 – June 2023) for articles that included a model, scenario, or simulation of pandemic resources and/or describe resource parameters, for example personal protective equipment (PPE) usage, length of stay (LoS) in intensive care unit (ICU), or vaccine efficacy. Papers with data on resource parameters from all countries were included. Results We identified 2754 articles of which 147 were included in the final review. Forty-six different resource parameters with values related to non-ICU beds (n = 43 articles), ICU beds (n = 57), mechanical ventilation (n = 39), healthcare workers (n = 12), pharmaceuticals (n = 21), PPE (n = 8), vaccines (n = 26), and testing and tracing (n = 19). Differences between resource types related to pandemic influenza and COVID-19 were observed, for example on mechanical ventilation (mostly for COVID-19) and testing & tracing (all for COVID-19). Conclusion This review provides an overview of public health and healthcare resources with associated parameters in the context of pandemic influenza and the COVID-19 pandemic. Providing insight into the ranges of plausible parameter values on the use of public health and healthcare resources improves the accuracy of results of modelling different scenarios, and thus decision-making by policy makers and hospital planners. This review also highlights a scarcity of published data on important public health resources.

Abstract Background Outbreaks with multidrug-resistant organisms (MDROs) are a significant burden on the healthcare system and the wellbeing of affected patients and carriers. Cross-institutional MDRO outbreaks require a concerted multidisciplinary effort for effective outbreak management. This presents challenges regarding cooperation, coordination and communication between stakeholders. In this study, we investigate collaborative structures and coordination roles in Dutch outbreak response networks and how Dutch healthcare professionals engage in preparedness activities relating to MDRO outbreaks. These findings form the basis for the development of a stress test exercise for improving professional and organizational collaboration and coordination during MDRO outbreaks. Methods Using a mixed-methods design, an online survey and qualitative interviews are conducted among healthcare professionals in two healthcare regions in the Netherlands. Social network analysis is used to gain insight in collaborative structures and brokerage roles. To investigate preparedness activities, the survey is combined with qualitative interviews to explore respondents’ experiences, preferences and needs regarding preparedness activities for MDRO outbreak management. Results During the workshop we will show the cross-organizational network structures, the strengths and weakness of the mutual connections and provide insight in positions in networks, roles and responsibilities. Also, we provide insight in how the use of and experience with training and exercise activities, such as stress tests, contribute to preparedness for MDRO outbreaks in vulnerable patient populations. Conclusions This study shows how healthcare professionals from different organizations collaborate during MDRO outbreaks, and how they engage with preparedness activities. This provides valuable input for development of a stress test specific to MDRO outbreak management, and other interventions to improve outbreak preparedness.

In October 2023, the World Health Organization (WHO) published a proposal for a Pandemic Agreement, the first proposed document on pandemic prevention, preparedness and response drafted at world scale [ 1 WHO. Revised draft of the negotiating text of the WHO Pandemic Agreement. 13 March 2024. Available at: https://apps.who.int/gb/inb/pdf_files/inb9/A_inb9_3-en.pdf (Last accessed: 20 April 2024) Google Scholar , 2 The LancetThe Pandemic Treaty: shameful and unjust. Lancet. 2024; 403: 781https://doi.org/10.1016/S0140-6736(24)00410-0 Abstract Full Text Full Text PDF Scopus (4) Google Scholar , 3 Schwalbe N. Hannon E. Lehtimaki S. The new pandemic treaty: Are we in safer hands? Probably not. BMJ. 2024; 384: q477https://doi.org/10.1136/bmj.q477 Crossref Scopus (0) Google Scholar ]. A revised draft of the negotiating text of the WHO Pandemic Agreement has been released in March 2024 [ 1 WHO. Revised draft of the negotiating text of the WHO Pandemic Agreement. 13 March 2024. Available at: https://apps.who.int/gb/inb/pdf_files/inb9/A_inb9_3-en.pdf (Last accessed: 20 April 2024) Google Scholar , 2 The LancetThe Pandemic Treaty: shameful and unjust. Lancet. 2024; 403: 781https://doi.org/10.1016/S0140-6736(24)00410-0 Abstract Full Text Full Text PDF Scopus (4) Google Scholar , 3 Schwalbe N. Hannon E. Lehtimaki S. The new pandemic treaty: Are we in safer hands? Probably not. BMJ. 2024; 384: q477https://doi.org/10.1136/bmj.q477 Crossref Scopus (0) Google Scholar ]. This document provides a significant step forward in joining forces and maintaining the momentum of infectious disease outbreak preparedness and response, that evolved during the SARS-CoV-2 pandemics.

ObjectiveThe COVID-19 pandemic highlighted the crucial role of healthcare and public health resource management, where scarcity impairs pandemic response resulting in increased disease transmission, delayed patient care and poorer health outcomes. In the EU PANDEM-2 project, we aimed to identify essential resource parameters for pandemic preparedness and response in the context of an emerging viral respiratory illness.DesignAfter performing a systematic literature review, we conducted a Delphi study consisting of a structured questionnaire and consensus round with two separate panels of European public health experts (PHEs) and clinicians, respectively. Resources were categorised as material (n=23), human (n=18) or pharmaceutical (n=12). Data were analysed descriptively for both panels.ResultsParticipants were 17 PHEs and 16 clinicians from nine countries. Consensus between the two panels was found on 40 resource parameters (17 material, 14 human, 9 pharmaceutical; 33 accepted and 7 rejected). Notably, clinicians selected three home care resources while PHEs did not, and PHEs selected two pharmaceutical resources which clinicians did not. No consensus was observed on 13 resources. Eleven additional resources were suggested and included (five for PHE and six for clinicians) among which were personal protective equipment for mobile teams, resources for primary care and resources related to mechanical ventilation.ConclusionsThe high level of consensus between the two expert panels indicates common goals in pandemic resource planning. The disagreement on 13 resource parameters reflects the different priorities between PHEs and clinicians in pandemic planning. This study has demonstrated the core components of resource modelling required for pandemic preparedness planning and shows the importance of consulting experts with both public health and clinical backgrounds. Including our proposed resources in pandemic models allows for more enhanced planning and training activities for future pandemics.

Background: The Radboudumc developed a smartphone application ( WondGezond ) to collect surgical wound-healing information provided by the patient. Aim: To evaluate usability and outcomes to assess its potential for early surgical site infection (SSI) detection. Methods: Patients surgically treated for degenerative spinal disorders or carpal tunnel syndrome between August 2020 and February 2023 were enrolled one day post surgery and asked to download the app via a quick -response (QR) code. Participants uploaded a photo and answered four questions about their wound daily, for 14 days. Afterwards, participants indicated whether they received treatment for a suspected SSI (participantreported outcome). Two neurosurgeons independently assessed photos and questionnaire answers for suspected SSIs (physician-assessed outcome). The association between both outcomes was determined by calculating sensitivity, specificity, and positive and negative predictive value (PPV/NPV). Findings: After 2009 surgeries, 1695 QR-codes were distributed and 412 (21%) were activated. In all, 232 (56%) participants completed the 14 -day period of whom 22 (10%) reported SSI treatment. Physician assessment identified 15 (7%) SSIs. Concordance was reached in 88% of cases. Among 27 discordant cases were 17 false -positives and 10 falsenegatives, resulting in low sensitivity (33%) and PPV (23%), but high NPV (95%). Conclusion: WondGezond provides clinicians with information regarding wound healing and SSIs to follow-up on patients at risk, while possibly also reducing antibiotic (over) treatment and unnecessary visits for patients without issues in wound healing. However, the low participation and false -positive results render the app in its current form unsuitable for surveillance purposes. Further validation of WondGezond is required.

Patients with high-consequence infectious diseases (HCIDs) require high-quality care by specially trained staff in a high-level isolation unit (HLIU) that follows strict infection prevention and control (IPC) measures. Caring for patients with (suspected) HCID is challenging, mainly because of the strict personal protective equipment (PPE) and IPC protocols healthcare workers (HCW) must adhere to for protection. The Radboud University Medical Center, located in Nijmegen, the Netherlands, has been a dedicated HLIU facility since 2008. A newly built HLIU opened in May 2022, and encouraged us to review the existing PPE selection, IPC protocols, and HCID training program to improve safety and comfort for HCWs working in the HLIU. Based on a systematic search through (inter)national HCID PPE guidelines and semistructured interviews with end users, we selected an improved, more comfortable set of PPE. Additionally, we developed a more concise and easier-to-use patient care process flow and implemented a new teaching strategy. The new way of working was tested in October 2022 when the first 2 patients with suspected HCID were admitted to our unit. We used surveys to evaluate the experiences of HCWs involved in this care to further improve the workflow of the unit. When optimizing safety and comfort for HCWs, it is important to consider (inter)national guidelines as well as user preferences. By systematically evaluating recent experiences of patient admission to the HLIU and then adjusting protocols and training, we can ensure that the quality of provided healthcare and the safety of HCWs working in the HLIU remains high.

In recent years, field epidemiologists have embraced rapidly evolving digital tools, data sources and technologies, and collaborated with an ever-growing field of scientific specialisms. The COVID-19 pandemic put field epidemiology under unprecedented demand and scrutiny. As the COVID-19 emergency recedes, it is timely to reflect on the core values of our profession and the unique challenges and opportunities that lie ahead. In November 2022, alumni of the European Programme for Intervention Epidemiology Training (EPIET) and the European Public Health Microbiology (EUPHEM) training programme celebrated 25 years of EPIET, and the present and future of field epidemiology was discussed. The output was recorded and qualitatively analysed. This Perspective reflects the authors' interpretation of the discussion. We should reaffirm our commitment to field epidemiology's core strengths: competence and rigour in epidemiology, surveillance, outbreak investigation and applied research, leading to timely and actionable evidence for public health. Our future success will be defined by an ability to adapt, collaborate, harness innovation, communicate and, ultimately, by our tangible impact on protecting and improving health.

Background Genital tract infections pose a public health concern. In many low-middle-income countries, symptom-based algorithms guide treatment decisions. Advantages notwithstanding, this strategy has important limitations. We aimed to determine the infections causing lower genital tract symptoms in women, evaluated the Kenyan syndromic treatment algorithm for vaginal discharge, and proposed an improved algorithm. Methods This cross-sectional study included symptomatic non-pregnant adult women presenting with lower genital tract symptoms at seven outpatient health facilities in Nairobi. Clinical, socio-demographic information and vaginal swabs microbiological tests were obtained. Multivariate logistic regression analyses were performed to find predictive factors for the genital infections and used to develop an alternative vaginal discharge treatment algorithm (using 60% of the dataset). The other 40% of data was used to assess the performance of each algorithm compared to laboratory diagnosis. Results Of 813 women, 66% had an infection (vulvovaginal candidiasis 40%, bacterial vaginosis 17%, Neisseria gonorrhoea 14%, multiple infections 23%); 56% of women reported ≥ 3 lower genital tract symptoms episodes in the preceding 12 months. Vulvovaginal itch predicted vulvovaginal candidiasis (odds ratio (OR) 2.20, 95% CI 1.40–3.46); foul-smelling vaginal discharge predicted bacterial vaginosis (OR 3.63, 95% CI 2.17–6.07), and sexually transmitted infection ( Neisseria gonorrhoea, Trichomonas vaginalis , Chlamydia trachomatis , Mycoplasma genitalium ) (OR 1.64, 95% CI 1.06–2.55). Additionally, lower abdominal pain (OR 1.73, 95% CI 1.07–2.79) predicted sexually transmitted infection. Inappropriate treatment was 117% and 75% by the current and alternative algorithms respectively. Treatment specificity for bacterial vaginosis/ Trichomonas vaginalis was 27% and 82% by the current and alternative algorithms, respectively. Performance by other parameters was poor to moderate and comparable between the two algorithms. Conclusion Single and multiple genital infections are common among women presenting with lower genital tract symptoms at outpatient clinics in Nairobi. The conventional vaginal discharge treatment algorithm performed poorly, while the alternative algorithm achieved only modest improvement. For optimal care of vaginal discharge syndrome, we recommend the inclusion of point-of-care diagnostics in the flowcharts.

We present the findings from the European Programme for Intervention Epidemiology Training (EPIET) Alumni Network (EAN) Member Survey conducted in October to December 2021. The EAN consists of field epi-demiologists (EPIET) and public health microbiolo-gists (European Public Health Microbiology Training Programme (EUPHEM)) who stay connected after their 2-year fellowship. This active alumni network provides opportunities for career development, mentorship, knowledge exchange and sharing of best practices for community members, affiliated professionals and public health organisations in Europe. Overall, 281 of 732 members participated in the survey. Of the 192 European fellowship alumni respondents, 173 (90%) indicated that skills and competencies acquired dur-ing their fellowship improved performance in their role compared with their abilities before the fellow-ship. Reported skills and competencies that could be further strengthened included data management/ analysis, communication, mathematical modelling and leadership/team management. The EAN Member Survey provides valuable feedback to the EAN, as well as the fellowship programme offices at the European Centre for Disease Prevention and Control (ECDC) and affiliated field epidemiology programmes. The COVID-19 pandemic was a stark reminder of how essen-tial cross-border collaborations are for continued European health security. Maintaining and increasing the professional, well-trained workforce remains cru-cial for optimal response to infectious diseases and protection of public health.

We analysed SARS-CoV-2 PCR Cq values from 3,183 healthcare workers who tested positive between January and August 2022. Median Cq values were lower in symptomatic than in asymptomatic HCW. The difference in Cq values between HCW with mild vs moderate/severe symptoms was statistically significant but negligibly small. To prevent nosocomial infections, all symptomatic HCW should be tested irrespective of symptom severity. This information can support decisions on testing and isolation, in the context of ongoing pressure on healthcare systems.

Population Medicine considers the following types of articles:• Research Papers -reports of data from original research or secondary dataset analyses.• Review Papers -comprehensive, authoritative, reviews within the journal's scope.These include both systematic reviews and narrative reviews.• Short Reports -brief reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -articles describing a research protocol of a study.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.

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Abstract Background We evaluated the success rate of MRSA decolonization directly after treatment and after one year in patients who were treated at the outpatient MRSA clinic of a large university medical centre to identify potential contributing factors to treatment success and failure. Methods Data from November 1, 2013 to August 1, 2020 were used. Only patients who had undergone complete MRSA decolonization were included. Risk factors for MRSA treatment failure were identified using a multivariable logistic regression model. Results In total, 127 MRSA carriers were included: 7 had uncomplicated carriage, 91 had complicated carriage, and 29 patients had complicated carriage in combination with an infection. In complicated carriers and complicated carriers with an infection final treatment was successful in 75.0%. Risk factors for initial treatment failure included having one or more comorbidities and not testing the household members. Risk factors for final treatment failure were living in a refugee centre, being of younger age (0–17 years), and having one or more comorbidities. Conclusions The results of this study indicate that patients with a refugee status and children treated at the paediatric clinic have a higher risk of MRSA decolonisation treatment failure. For this reason, it might be useful to revise decolonization strategies for these subgroups and to refer these patients to specialized outpatient clinics in order to achieve higher treatment success rates.

Background Terminal cleaning and disinfection of hospital patient rooms must be performed after discharge of a patient with a multidrug resistant micro-organism to eliminate pathogens from the environment. Terminal disinfection is often performed manually, which is prone to human errors and therefore poses an increased infection risk for the next patients. Automated whole room disinfection (WRD) replaces or adds on to the manual process of disinfection and can contribute to the quality of terminal disinfection. While the in vitro efficacy of WRD devices has been extensively investigated and reviewed, little is known about the in situ efficacy in a real-life hospital setting. In this review, we summarize available literature on the in situ efficacy of WRD devices in a hospital setting and compare findings to the in vitro efficacy of WRD devices. Moreover, we offer practical recommendations for the implementation of WRD devices. Methods The in situ efficacy was summarized for four commonly used types of WRD devices: aerosolized hydrogen peroxide, H 2 O 2 vapour, ultraviolet C and pulsed xenon ultraviolet. The in situ efficacy was based on environmental and clinical outcome measures. A systematic literature search was performed in PubMed in September 2021 to identify available literature. For each disinfection system, we summarized the available devices, practical information, in vitro efficacy and in situ efficacy. Results In total, 54 articles were included. Articles reporting environmental outcomes of WRD devices had large variation in methodology, reported outcome measures, preparation of the patient room prior to environmental sampling, the location of sampling within the room and the moment of sampling. For the clinical outcome measures, all included articles reported the infection rate. Overall, these studies consistently showed that automated disinfection using any of the four types of WRD is effective in reducing environmental and clinical outcomes. Conclusion Despite the large variation in the included studies, the four automated WRD systems are effective in reducing the amount of pathogens present in a hospital environment, which was also in line with conclusions from in vitro studies. Therefore, the assessment of what WRD device would be most suitable in a specific healthcare setting mostly depends on practical considerations.

Objectives: Inappropriate antibiotic dispensing is one of the key drivers of antibiotic resistance. This review documents the effectiveness of interventions aimed at improving antibiotic dispensing practices at the community level by drug dispensers in low- and middle-income countries (LMIC). Methods: We conducted a systematic search in PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science (11 November 2019). Studies were included if they reported data on the outcome measure: appropriate dispensing of medicine including antibiotics. The effectiveness of studies was assessed based on quantitative results reported in the studies included. Results: A total of 1158 articles were screened. Thirteen studies from Asia (six), Africa (five) and South America (one) and one study from both Africa and Asia were included in this review. Nine (69.2%) studies reported significant effectiveness of interventions on all or more than 50% of antibiotic-related outcomes. Cochrane Effective Practice and Organization of Care interventions frequently applied were educational meetings (9/13), distribution of educational materials (7/13), educational outreach meetings (7/13), reminders (6/13), local consensus processes (6/13), distribution of supplies (6/14) and clinical practice guidelines (4/14), Nine studies reported on stakeholder involvement. Conclusion: This review shows that it is possible to improve antibiotic dispensing practices at the community level in LMIC. Stakeholders' involvement was key in the design and implementation of interventions. (C) 2022 The Author(s). Published by Elsevier Ltd on behalf of International Society for Antimicrobial Chemotherapy.

Antituberculosis drug-induced hepatotoxicity (ATDH) complicates the treatment of 5-10% of patients treated for active tuberculosis (TB). Knowledge regarding the mechanism of toxicity is still incomplete. Metabolism and the formation of toxic metabolites of the TB drugs may play an important role in the development of ATDH. We studied hepatotoxicity and interactions between isoniazid (INH), its toxic metabolite hydrazine (HYD), rifampicin (RIF) and pyrazinamide (PZA) in human hepatoma cells (HepG2). After 24h pre-treatment with a non-toxic concentration of one of the four compounds, cells were exposed to increasing concentrations of INH, HYD, RIF or PZA. To determine whether pre-treatment increased toxicity, changes in the concentration at which 50% of cell growth was inhibited (IC50) were quantified using the WST-1 cytotoxicity assay. Pre-treatment with INH, HYD or RIF decreased the INH IC50 by 24%, 26% and 15%, respectively, meaning that INH toxicity was increased. INH and HYD pre-treatment decreased the PZA IC50 by 30% and 38%, respectively. HYD and RIF toxicity were not affected by the pre-treatments. The present study is the first to demonstrate that pre-treatment with INH or its toxic metabolite HYD increases the in vitro toxicity of PZA. In addition, pre-treatment with INH, HYD or RIF increases the in vitro toxicity of INH. These results give us greater insight into the development of ATDH.