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Background: In December 2019, the maternal pertussis vaccination (MPV) became part of the Dutch National Immunization Program. This study aims to study MPV behavior and associated psychosocial, attitudinal and organizational factors of pertussis vaccination behavior during pregnancy in the Netherlands., Methods: We conducted a cross-sectional survey among pregnant women and recent mothers, up to six months post-partum. The primary outcome measure of this study was MPV behavior. Associations between psychosocial, attitudinal and organizational factors and MPV behavior were assessed using univariate and multivariate binary logistic regression analysis., Results: In total 1348 participants filled out the questionnaire, including 1282 (95.1%) MPV acceptors and 66 (4.9%) MPV refusers. The most important factors associated with MPV behavior were: attitude (aOR: 10.19; 95%CI: 4.30-24.16), outcome expectations (aOR: 8.94; 95%CI: 3.60-22.21), omission bias (aOR: 0.11; 95%CI: 0.02-0.59) and physical accessibility (aOR: 7.44; 95%CI: 3.37-16.46)., Conclusion: Pregnant women make their decision about the MPV primarily based on attitudinal and psychosocial factors, such as outcome expectations and attitude. A combination and variation of different messages, about the advantages (effectiveness) and disadvantages (side effects) of maternal vaccination, can be used in reaching pregnant women with a positive and negative attitude about the MPV. In addition, strategies to increase MPV uptake should not only focus on providing information, but also decrease experienced practical barriers, such as poor physical accessibility, in people that are intended to receive the MPV but are not getting vaccinated., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: The detection of low levels of antibodies against HBsAg (anti-HBs) below 10 IU/L in non-responders after a primary hepatitis B vaccination, is associated with seroconversion after revaccination. We compared the diagnostic performance of four anti-HBs assays in non-responders in their ability to differentiate between absence or presence of low levels of anti-HBs and propose a revaccination strategy guided by anti-HBs titres., Methods: Non-responders were revaccinated with Fendrix 20 μg at 0, 1 and 2 months. Anti-HBs titres were determined by Abbott Architect, Diasorin Liaison, Roche Cobas and Siemens ADVIA Centaur. Inter-assay agreement was evaluated with Cohen's Kappa (k) in baseline samples between zero-responders without detectable antibodies and poor-responders with detectable antibodies < 10 IU/L. Seroconversion rates and geometric mean titres were analysed at 0, 1 and 3 months. A titre-based strategy (one revaccination dose and anti-HBs measurement followed by two more revaccination doses if required) was compared with the standard revaccination series of 3 doses., Results: 57 participants were included in the analysis. k was ≥ 0.65 for all assays except ADVIA (k ≤ 0.41). After one revaccination dose all assays detected a mean seroconversion rate in zero-responders of 42.9%, compared to 85.1% in poor-responders. The difference between zero- and poor-responders in seroconversion rate per assay was significant (p < 0.05). After three revaccination doses the mean seroconversion rate was 88.2% in zero-responders and 98.5% in poor-responders (p > 0.286 per assay). A titre-based strategy reduced the amount of revaccinations by 17% compared with the standard., Conclusions: All assays demonstrated a comparable difference in seroconversion rate between zero- and poor-responders after one revaccination dose. The revaccination strategy could be optimised by differentiation between zero- and poor-responders followed by a titre-guided schedule., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: GlaxoSmithKline and Merck Sharp & Dohme provided the vaccines used in the trial from which we obtained the participant data and serum samples for this study. Neither manufacturer was involved in the study design, data collection, data analysis, interpretation of the results, or writing of the report., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Pharyngeal Chlamydia trachomatis in women might contribute to autoinoculation and transmission to sexual partners. Data for effectiveness of different testing practices for pharyngeal C trachomatis are scarce. We therefore aimed to assess the prevalence of pharyngeal C trachomatis, determinants, and effectiveness of different testing practices in women., Methods: We did a retrospective cohort study, in which surveillance data for all women visiting sexually transmitted infection clinics in all regions in the Netherlands between Jan 1, 2008, and Dec 31, 2017, were used. We collected consultation-level data and individual-level data from 2016 onwards for sociodemographic characteristics, sexual behaviour in the past 6 months, self-reported symptoms, and STI diagnoses. The primary outcome was the positivity rate of pharyngeal C trachomatis infection compared between routine universal testing (>85% tested pharyngeally per clinic year), selective testing (5-85% tested pharyngeally per clinic year), and incidental testing (<5% pharyngeally tested per clinic year). We calculated the number of missed infections by extrapolating the positivity rate assessed by routine universal testing to all selectively tested women. We used multivariable generalised estimating equations logistic regression analyses to assess independent risk factors for pharyngeal C trachomatis and used the assessed risk factors as testing indicators for comparing alternative testing scenarios., Findings: Between Jan 1, 2008, and Dec 31, 2017, a total of 550 615 consultations with at least one C trachomatis test was recorded, of which 541 945 (98·4%) consultations (including repeat visits) were included in this analysis. Pharyngeal C trachomatis positivity was lower in the routine universal testing group than in the selective testing group (1081 [2·4%; 95% CI 2·2-2·5] of 45 774 vs 3473 [2·9%; 2·8-3·0] of 121 262; p<0·0001). The positivity rate was also higher among consultations done in the incidental testing group (44 [4·1%; 95% CI 3·1-5·5] of 1073; p<0·0001) than in the routine universal testing group. Based on extrapolation, selective testing would have hypothetically missed 64·4% (95% CI 63·5-65·3; 6363 of 9879) of the estimated total of C trachomatis infections. The proportion of pharyngeal-only C trachomatis was comparable between routinely universally tested women (22·9%) and selectively tested women (20·4%), resulting in a difference of 2·5% (95% CI -0·3 to 5·3; p=0·07). When using risk factors for pharyngeal C trachomatis as testing indicators, 15 484 (79·6%) of 19 459 women would be tested to detect 398 (80·6%) of 494 infections., Interpretation: No optimal testing scenario was available for pharyngeal C trachomatis, in which only a selection of high-risk women needs to be tested to find most pharyngeal C trachomatis infections. The relative low prevalence of pharyngeal-only C trachomatis (0·5%) and probably limited clinical and public health effect do not provide support for routine universal testing., Funding: Public Health Service South Limburg., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Women are not routinely tested for oropharyngeal Neisseria gonorrhoeae. At present, selective testing based on sexual behaviour or risk groups is advocated by international guidelines. Many oropharyngeal infections are asymptomatic and thus remain undetected, establishing a reservoir for ongoing transmission. Data on effectiveness of routine testing are scarce, thus we aimed to assess the optimal testing strategy for oropharyngeal N gonorrhoeae in women., Methods: In this retrospective cohort study, we used surveillance data obtained from all sexually transmitted infection (STI) clinics in the Netherlands between Jan 1, 2008, and Dec 31, 2017. We collected consultation-level data, and individual-level patient data from 2016 onwards, on sociodemographic characteristics, sexual behaviour in the past 6 months, self-reported symptoms, and STI diagnoses. We compared the prevalence of oropharyngeal N gonorrhoeae between women who attended clinics that offered routine universal testing (defined as >85% of women tested per clinic-year) and women who attended clinics that offered selective testing (defined as 5-85% of women tested per clinic-year) or incidental testing (<5% of women tested per clinic-year). We calculated the number of infections missed by selective testing by extrapolating prevalence for the routine universal testing group to that of weighted and unweighted samples of all selectively tested women. We used multivariable generalised estimating equations to identify independent risk factors for oropharyngeal N gonorrhoeae to identify the optimal selective testing strategy., Findings: 554 266 consultations with at least one N gonorrhoeae test were recorded, of which 545 750 consultations (including repeat visits) were included in the analyses. Of 545 750 consultations, routine universal testing was used in 57 359 (10·5%), selective testing in 444 283 (81·4%), and incidental testing in 44 108 (8·1%). The prevalence of oropharyngeal N gonorrhoeae was 1·4% (95% CI 1·3-1·5; 703 of 50 962 consultations) in the routine testing group compared with 1·4% (1·3-1·5; 1858 of 132 276) in the selective testing group (p=0·68) and 2·8% (1·9-3·9; 30 of 1088) in the incidental testing group (p<0·0001). The prevalence of oropharyngeal-only infections was 47·7% (335 of 703 women) in the routine testing group, 53·3% (991 of 1858) in the selective testing group, and 60·0% (18 of 30) in the incidental testing group. Selective testing would have missed an estimated 4363 (70%; 95% CI 69-71) of all 6221 oropharyngeal N gonorrhoeae infections. Independent risk factors for oropharyngeal N gonorrhoeae were being notified for any STI (adjusted odds ratio 2·1, 95% CI 1·5-3·0), reporting sex work (4·0, 2·3-6·7), and having concurrent genital (51·5, 34·1-77·7) or anorectal (2·6, 1·4-4·8) N gonorrhoeae. Selective testing of women notified for any STI, or who reported sex work, would have led to 5418 (27·8%) of 19 455 women being tested and would have identified 119 (55·6%) of 214 oropharyngeal N gonorrhoeae infections., Interpretation: Selective testing potentially misses more than two-thirds of oropharyngeal N gonorrhoeae infections in women, of whom half have oropharyngeal infections without concurrent genital or anorectal infections. Using independent risk factors for oropharyngeal infection to guide testing is a minimal testing strategy. Routine universal testing is the optimum scenario to detect the majority of infections. However, future studies are needed to assess the cost-effectiveness of routine testing and its effect on antimicrobial resistance., Funding: Public Health Service South Limburg., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: In 2009, girls-only HPV16/18 vaccination was introduced in the Netherlands which has achieved 46-61% uptake. Heterosexual men have benefitted from herd protection, but it is unknown whether men who have sex with men (MSM) also benefit from herd effects of the girls-only HPV16/18 vaccination program. Because MSM bear a high HPV-related disease burden, countries might consider targeted vaccination for MSM. To study possible herd effects and prior HPV exposure at a potential moment of vaccination, we assessed trends in the HPV prevalence and proportions (sero)negative for the various vaccine types among young MSM visiting sexual health centers (SHCs)., Methods: We used data from MSM included in PASSYON study years 2009-2017. In this biennial cross-sectional study among visitors of SHCs aged 16-24 years, MSM provided a penile and anal swab for HPV DNA testing (including vaccine types HPV6/11/16/18/31/33/45/52/58) and blood for HPV antibody testing (HPV16/18/31/33/45/52/58)., Results: In total 575 MSM were included, with a median of 22 years of age and 15 lifetime sex partners and 3.5% HIV positive. Trends in penile or anal HPV prevalence during 2009-2017 were statistically non-significant for all vaccine types. Of the 455 MSM with a penile and anal swab, 360 (79%), 283 (62%) and 242 (53%) were HPV DNA negative at both anatomical sites for HPV16/18, HPV6/11/16/18 and HPV6/11/16/18/31/33/45/52/58 respectively. Among MSM who were HPV16/18 and HPV16/18/31/33/45/52/58 DNA negative and were tested for serology (n = 335 and 279 respectively), 82% and 71% were also seronegative for the respective types., Discussion: There were no significant declines in the HPV prevalence among MSM up to eight years after introduction of girls-only HPV16/18 vaccination, indicating that MSM are unlikely to benefit largely from herd effects from girls-only vaccination. Most MSM were vaccine-type DNA negative and seronegative, suggesting that vaccination of young MSM visiting SHCs could still be beneficial., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Serological non-response can be present after hepatitis B vaccination in healthy adults. We aimed to establish which of three revaccination regimens is most effective at inducing protective immunity METHODS: Healthy adults (aged 18-80 years) from 16 Dutch centres (13 public health services, two university hospitals, and one travel clinic) were included in this multicentre, parallel group, randomised, controlled, superiority trial. The inclusion criterion was vaccine non-response (hepatitis B surface antibody [anti-HBs] titre <10 IU/L) after a primary series with three doses of one type of recombinant vaccine against hepatitis B virus (either HBVaxPro-10 or Engerix-B at months 0, 1, and 6). Participants were individually randomly assigned (1:1:1:1) to a vaccination series of repeated initial vaccination (HBVaxPro 10 μg or Engerix-B 20 μg) as the control, or to Twinrix 20 μg, Fendrix 20 μg, or HBVaxPro 40 μg. We used a web-based randomisation programme, stratified by centre, with a block size of four. Participants and centres were unmasked to assignment after randomisation. Laboratory staff and investigators were masked to vaccine-group assignment. All revaccination schedules were identical, with intramuscular vaccinations at 0, 1, and 2 months. Anti-HBs was measured at 0, 1, 2, and 3 months. The primary outcome was the percentage of responders (anti-HBs titres ≥10 IU/L) at 3 months. Immunogenicity and safety analyses were based on an intention-to-vaccinate analysis, the immunogenicity analysis with last observation carried forward for missing data, and the Bonferroni and the Benjamini-Hochberg method were applied to correct for multiple testing. The trial was registered in the Dutch National Trial Register and inclusion has been stopped (identifier NL3011; EudraCT-number 2011-005627-40)., Findings: The participants were recruited between Nov 1, 2012, and Sept 1, 2017. 480 participants were randomly assigned and included in intention-to-vaccinate analyses: 124 (26%) to control, 118 (25%) to Twinrix, 114 (24%) to HBVaxPro-40, and 124 (26%) to Fendrix. At month 3 the percentage of responders was 83 (67%) of 124 (95% CI 57·9-75·1 in the control group, 94 (80%) of the 118 (71·3-86·5) in the Twinrix group, 95 (83%) of 114 (75·2-89·7) in the HBVaxPro-40 group, and 108 (87%) of 124 (79·9-92·4) in the Fendrix group. Compared with the control group, the percentage of responders was superior for the HBVaxPro-40 group (adjusted difference 21·6% [95% CI 10·4-32·7], p=0·0204 [Bonferroni corrected p value]) and the Fendrix group (26·3% [15·4-37·3], p=0·0006), but not the Twinrix group (25·0% [13·0-37·0]; p=0·0846). One serious adverse event occurred (herpes zoster ophthalmicus) in the Fendrix group, which was not attributed to the vaccine., Interpretation: Revaccinating healthy non-responders with Fendrix or HBVaxPro-40 resulted in significantly higher proportions of responders and therefore indication for these vaccines should be expanded to enable revaccination of non-responders., Funding: National Institute for Public Health and the Environment., (Copyright © 2020 Elsevier Ltd. All rights reserved.)