Vaccination has reduced the disease burden of vaccine-preventable diseases. However, the extent to which seasonal cycles of immunity could influence vaccine-induced immunity is not well understood. A national cross-sectional serosurveillance study performed in the Netherlands (Pienter-2) yielded data to investigate whether season of vaccination was associated with antibody responses induced by DT-IPV (diphtheria, tetanus and poliomyelitis), MMR (measles, mumps and rubella) and meningococcus C (MenC) vaccines in children. In total, 434 children met the inclusion criteria to study DT-IPV immunity, 811 for MMR and 311 for MenC. Differences in log(antibody levels) by season of vaccination were investigated with linear multivariable regression analyses. Seroconversion rates varied according to season of vaccination for rubella (90% of autumn-vaccinated children vs. 99% of winter-vaccinated had concentrations above cut-off levels). Summer-vaccinated boys showed a slower decline of tetanus antibodies (6% per month), in comparison with winter-vaccinated boys. In conclusion, season of vaccination showed little association with immunological protection. However, a number of associations were seen with a P-value of about 0.03; and adding data from a just-completed nationwide serological study might add more power to the current study. Further immunological and longitudinal investigations could help understand the mechanisms of seasonal influence in vaccine-induced responses.

increased for the 1st and 3rd months and continuity of medication was higher at 3rd month. Conclusions:WhatsApp support embedded in cessation service delivery increases the success rate and has favorable effects on followup.More over, the equalizing effect of the intervention in terms of socioeconomic differences, positively contributes to the elimination of inequalities for successful smoking cessation in disadvantaged groups.

SETTING AND OBJECTIVE:In low-incidence countries, most tuberculosis (TB) cases are foreign-born. We explored the temporal relationship between immigration and TB in first-generation immigrants between 1995 and 2012 to assess whether immigration can be a predictor for TB in immigrants from high-incidence countries.DESIGN:We obtained monthly data on immigrant TB cases and immigration for the three countries of origin most frequently represented among TB cases in the Netherlands: Morocco, Somalia and Turkey. The best-fit seasonal autoregressive integrated moving average (SARIMA) model to the immigration time-series was used to prewhiten the TB time series. The cross-correlation function (CCF) was then computed on the residual time series to detect time lags between immigration and TB rates.RESULTS:We identified a 17-month lag between Somali immigration and Somali immigrant TB cases, but no time lag for immigrants from Morocco and Turkey.CONCLUSION:The absence of a lag in the Moroccan and Turkish population may be attributed to the relatively low TB prevalence in the countries of origin and an increased likelihood of reactivation TB in an ageing immigrant population. Understanding the time lag between Somali immigration and TB disease would benefit from a closer epidemiological analysis of cohorts of Somali cases diagnosed within the first years after entry.

The PROHIBIT study aimed at inventorying and analysing national and local infection prevention activities in Europe and to test two interventions of proven efficacy in central venous catheter (CVC) bloodstream infection (CRBSI) reduction: a multimodal CVC bundle and a multimodal hand hygiene (HH) improvement strategy.

Introduction: Although both coagulation and fibrinolysis are associated with cardiovascular disease (CVD) the underlying nature and pathways of many of these associations are still unclear. Our aim was to determine which of the current or 5-year prior levels of total fibrinogen, fibrinogen gamma', plasminogen activator inhibitor-1 (PAI-1(act)) and global fibrinolytic potential were the stronger determinant of arterial structure and function.Materials and methods: This prospective study consisted of 2010 Africans over the age of 35 years with 5-year follow-up data available for 1288 participants. Cardiovascular measurements included arterial stiffness, blood pressure and carotid intima media thickness.Results: Fibrinogen gamma' showed stronger associations with blood pressure than total fibrinogen also in the presence of other CVD risk factors. PAI-1(act) was positively associated with blood pressure both cross-sectionally and prospectively, with the longitudinal association being the stronger determinant, also after adjustment for known CVD risk factors. Clot lysis time (CLT) was positively associated, both prospectively and crosssectionally, with intima media thickness and negatively with markers of arterial stiffness but not after adjustment for known CVD risk factors.Conclusions: Fibrinogen gamma' was more strongly associated with CVD function than total fibrinogen. PAI-1(act) was significantly associated with blood pressure with changes in PAI-1 levels preceding changes in blood pressure. Different mechanisms may be at play determining arterial wall stiffness/thickening and blood pressure as observed from the opposing associations with PAI-1act and CLT. CLT was not independently related to cardiovascular measures as its associations were weakened in the presence of other known CVD risk factors. (C) 2014 Elsevier Ltd. All rights reserved.

BACKGROUND:The incidence of extra-pulmonary tuberculosis (EPTB) in the Netherlands shows a seasonal trend, with a peak in spring and a trough in autumn. Possible causes of this peak are winter crowding and a seasonal decrease in immune competence in spring. A third explanation may be a reporting bias.OBJECTIVE:To investigate the role of winter crowding by a time-series analysis of notification data. DNA fingerprinting clustering status can differentiate between recent and remote infections. Seasonality in clustered cases would reflect enhanced transmission in winter and/or seasonally lowered immunity, while seasonality in unique cases would only reflect seasonally lowered immunity.METHODS:We fitted (seasonal) auto-regressive moving average models to culture-positive TB notifications in the Netherlands (1993-2008) to assess seasonality. We then used seasonal trend Loess decompositions to derive the seasonal pattern, and compared the heights of the seasonal peaks.RESULTS:Clustered and unique EPTB notifications showed a seasonal trend that was absent in clustered and unique PTB notifications. The seasonal peak in clustered EPTB cases was not significantly higher than in unique EPTB cases.CONCLUSIONS:The similar timing and height of the seasonal peak of clustered and unique EPTB cases suggests that winter crowding is unlikely to cause the seasonal trend in notifications.

Background Mental functioning is reported as an important outcome measure in patients with Rheumatoid Arthritis (RA). Patients show lower mental functioning scores than the general population (1). A factor that has great impact on the overall health outcomes is comorbidity (2). Both somatic and depression comorbidity are common in patients with RA. Investigating the influence of comorbidity on mental functioning provides clinicians long term information for a particular patient. Objectives To asses the long term association of somatic and depression comorbidity and mental functioning in patients with RA. Methods Longitudinal data over a period of eleven years were collected among 882 patients with RA of varying disease duration. Patient reported outcomes were collected in 1997, 1998, 1999, 2002 and 2008. Mental functioning was measured with the Mental Component Scale of the Short Form-36 Health Survey. Somatic comorbidity was measured by a self administered questionnaire including 13 chronic diseases. Depression comorbidity was measured with the Center for Epidemiologic Depression Scale. We distinguished four groups of patients based on comorbidity at baseline: patients 1) without comorbidity 2) with only somatic comorbidity 3) with only depression comorbidity and 4) with both somatic and depression comorbidity. The influence of comorbidity at baseline on mental functioning over time was investigated in a longitudinal analysis. Results 882 patients responded to the questionnaire, of whom 78% were women. The mean age of the patients at baseline was 59.3 (SD 14.8) years and the mean disease duration was 8.9 (SD 9.9) years. For the total group of patients with RA mental functioning stayed stable over time. There was no difference in mental functioning between patients without comorbidity and patients with somatic comorbidity. Patients without comorbidity at baseline had better mental functioning at all time points than patients with depression comorbidity and patients with both somatic and depression comorbidity (p<0.01). However, the difference in mental functioning between patients without comorbidity and patients with both somatic and depression comorbidity decreased between baseline and eleven years follow up (p<0.01). Conclusions Depression comorbidity and the combination of both somatic and depression comorbidity was negatively associated with mental functioning and this association was present during eleven years follow up. Because of its long term consequences, early screening for depression comorbidity in RA would be recommended, so additional intervention can start early in the disease process to reduce the negative effects of this comorbidity. References Uhlig T, Loge JH, Kristiansen IS, Kvien TK. Quantification of reduced health-related quality of life in patients with rheumatoid arthritis compared to the general population. J Rheumatol 2007; 34(6):1241-1247. Gabriel SE, Michaud K. Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases. Arthritis Res Ther 2009; 11(3):229. Disclosure of Interest None Declared

Background The prevalence of comorbidity in patients with rheumatoid arthritis (RA) is higher than in the general population (1). There is increasing evidence that comorbidity plays an important role in determining RA-related outcomes, like physical functioning (2). Little is known about the impact of comorbidity on the long term. Further, the studies that investigated the effects of comorbidity on physical functioning, did not compare the influence of both somatic and depression comorbidity. With this information clinicians can early adjust their treatment to the comorbidity. Objectives To asses the long term association of comorbidity and physical functioning in patients with established RA. Methods Longitudinal data were collected among 882 patients with RA of varying disease duration at inclusion in the study. Patient reported outcomes were collected in 1997, 1998, 1999, 2002 and 2008. Physical functioning was measured with the Health Assessment Questionnaire and the Physical Component Scale of the SF-36 Health Survey. Somatic comorbidity was measured by a self administered questionnaire including 13 chronic diseases. Depression comorbidity was measured with the Center for Epidemiologic Depression Scale. We distinguished four groups of patients based on comorbidity at baseline: patients 1) without comorbidity 2) with only somatic comorbidity 3) with only depression comorbidity and 4) with both somatic and depression comorbidity. The influence of comorbidity on physical functioning over time was investigated in a longitudinal analysis. Results 882 patients respond to the questionnaire, of whom 78% were woman. The mean (SD) age of the patients at baseline was 59.3 (SD 14.8) years and the mean (SD) disease duration was 8.9(SD 9.9) years. For the total group of patients with RA, physical functioning improved over an eleven year period. Patients with comorbidity had a worse physical functioning than patients without comorbidity at all time points, by which both groups with depression comorbidity had the lowest score (p<0.01). Only, patients with both somatic and depression comorbidity at baseline had significant less improvement in physical functioning over time (p<0.05). Conclusions Both somatic comorbidity and depression comorbidity had a negative impact on physical functioning during eleven years follow up in patients with RA, and their combination seems to be especially detrimental over time. Clinicians need to take somatic comorbidity and depression into account in screening and treatment of patients with rheumatoid arthritis to improve physical functioning in the long term. References Kroot EJ, van Gestel AM, Swinkels HL, Albers MM, van de Putte LB, van Riel PL. Chronic comorbidity in patients with early rheumatoid arthritis: a descriptive study. J Rheumatol 2001; 28(7):1511-1517. Gabriel SE, Michaud K. Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases. Arthritis Res Ther 2009; 11(3):229. Disclosure of Interest None Declared

BACKGROUND:Smoking is not associated with prostate cancer incidence in most studies, but associations between smoking and fatal prostate cancer have been reported. METHODS:During 1992 and 2000, lifestyle information was assessed via questionnaires and personal interview in a cohort of 145,112 European men. Until 2009, 4623 incident cases of prostate cancer were identified, including 1517 cases of low-grade, 396 cases of high grade, 1516 cases of localised, 808 cases of advanced disease, and 432 fatal cases. Multivariable Cox proportional hazards regression models were used to examine the association of smoking status, smoking intensity, and smoking duration with the risk of incident and fatal prostate cancer. RESULTS:Compared with never smokers, current smokers had a reduced risk of prostate cancer (RR=0.90, 95% CI: 0.83-0.97), which was statistically significant for localised and low-grade disease, but not for advanced or high-grade disease. In contrast, heavy smokers (25+ cigarettes per day) and men who had smoked for a long time (40+ years) had a higher risk of prostate cancer death (RR=1.81, 95% CI: 1.11-2.93; RR=1.38, 95% CI: 1.01-1.87, respectively). CONCLUSION:The observation of an increased prostate cancer mortality among heavy smokers confirms the results of previous prospective studies.

The first Dutch outbreak due to Clostridium difficile ribotype 027 was observed in mid-2005; by the end of that year, eight hospitals were affected. To study the relationship between hospital-wide antibiotic use and the incidence of 027-linked C. difficile-associated disease (CDAD) three study groups were made: group A, all eight hospitals with an 027-associated epidemic; group B, five of a total of six hospitals with occasional 027 cases, without an increase in CDAD; and group C, ten randomly selected hospitals with no reported 027 epidemics or isolated 027 cases. Quarterly data on CDAD incidences, hygiene measures and the use of fluoroquinolones, second- and third-generation cephalosporins, extended-spectrum penicillins, penicillins with beta-lactamase inhibitors, carbapenems, lincomycins and macrolides were collected for 2004 and 2005, and divided into pre-epidemic and epidemic periods. Using a multilevel Poisson regression analysis, CDAD incidence was linked to antibiotic use in the previous quarter and to certain hygiene measures. In the pre-epidemic period, the total use of the studied antibiotics was comparable between affected and unaffected hospitals. Higher use of second-generation cephalosporins, macrolides and all of the studied antibiotics were independently associated with a small increase in CDAD incidence [relative risk (95% confidence interval): 1.14 per increase of 100 defined daily doses per 10,000 bed days (1.06-1.23), 1.10 (1.01-1.19) and 1.02 (1.01-1.03), respectively]. However the effect was too small to predict which hospitals might be more prone to 027-associated outbreaks.

BACKGROUND:Better understanding of the association between early life lipid intakes and the development of allergic diseases is needed. OBJECTIVE:We prospectively studied breast milk content of n-6, n-3, and trans fatty acids in relation to allergic symptoms at the ages of 1 and 4 years. METHODS:Fatty acid content was determined in breast milk samples of 265 (158 allergic and 107 nonallergic) mothers of children participating in the Prevention and Incidence of Asthma and Mite Allergy study. Outcome variables studied were parental reported eczema at age 1 year, eczema at age 4 years, asthma at age 4 years, and, in a subgroup of 133 children, sensitization at age 4 years. RESULTS:In children of mothers with allergy, breast milk n-3 long chain polyunsaturated fatty acids and the ratio between n-3 and n-6 long chain polyunsaturated fatty acids were inversely associated with asthma and with persistent symptoms (eczema at age 1 year and eczema at age 4 years and/or asthma at age 4 years), but no associations between breast milk fatty acids and sensitization were observed. In children of mothers with allergy, also trans fatty acids tended to be inversely associated with allergic symptoms. In children of mothers without allergy, no associations between breast milk fatty acids and allergic symptoms were observed, but alpha-linolenic acid (18:3n-3) was positively associated with sensitization. CONCLUSION:In susceptible infants, the risk to develop allergic symptoms, but not the risk of sensitization, was modified by intake of n-3 long chain polyunsaturated fatty acids through breast milk.

The letter by Colquhoun et al points to the fact that during the publication of our review,1 simultaneous reports of an international research fraud investigation appeared, raising suspicion of the work of R.B. Singh. In our review, we used 3 publications by this author, which describe the dietary effects on mortality …

: Monday, June 14, 2004: ORAL SESSIONS: Poster Session 20: Epidemiology and Pharmacoeconomics

Ondanks de goede toegankelijkheid van de medische zorg in Nederland, verschilt de gezondheid tussen mensen met een lage en een hoge maatschappelijke positie. Het RIVM stelt een gestandaardiseerde meetmethode (indicator) voor waarmee deze gezondheidsverschillen kunnen worden weergegeven. Op die manier kunnen de verschillen in de gaten worden gehouden en kan worden getoetst of beleidsmatige maatregelen om ze te verkleinen, zoals initiatieven in wijken, effect hebben. De voorgestelde indicator geeft het verschil in levensverwachting weer tussen de 20 procent Nederlanders die de laagste maatschappelijke positie innemen en degenen die tot de hoogste 20 procent behoren. De maatschappelijke positie (sociaal economische status, ofwel SES) wordt doorgaans ontleend aan het opleidingsniveau of inkomen van mensen. Gezondheid is een complex begrip en omvat diverse kenmerken, waardoor dit onderzoek zich niet wil beperken tot een indicator. Om het overzichtelijk te houden wordt wel een kernindicator voorgesteld. Deze gebruikt het eigen oordeel van mensen over hun gezondheid als maat voor gezondheid en het opleidingsniveau als maat voor SES. Om nog andere aspecten van de gezondheid te belichten wordt voorgesteld om ook alternatieve gezondheidsmaten te berekenen. Momenteel zijn gegevens beschikbaar over de levensverwachting zonder lichamelijke beperkingen. In de toekomst komen gegevens beschikbaar die meer in lijn zijn met wat internationaal wordt gebruikt. Het betreft de levensverwachting zonder (door ziekte veroorzaakte) beperking van activiteiten, zoals naar werk of school gaan, en de levensverwachting zonder chronische ziekten. Voorgesteld wordt om in de toekomst deze gezondheidsmaten toe te voegen.