• Monitoringsrapportage NSL 2018 : Stand van zaken Nationaal Samenwerkingsprogramma Luchtkwaliteit

      Rutledge-Jonker, S; Wesseling, JP; Nguyen, PL; Visser, S; van Hooydonk, PR; Groot-Wassink, H; Sanders, A (Rijksinstituut voor Volksgezondheid en Milieu, 2018-12-19)
      Limit values are still exceeded locally In 2017, concentrations of nitrogen dioxide and particulate matter in most parts of the Netherlands were below European limit values. For nitrogen dioxide the number of locations where concentrations exceeded the limit value decreased compared to 2016. Exceedances still occurred on a number of busy inner city streets. Particulate matter concentrations still exceeded limit values at some locations, particularly those with intensive livestock farming. Trends in concentrations In 2017, the average concentration of nitrogen dioxide in the Netherlands decreased slightly compared to 2016. Both the average concentration and the number of exceedances in inner cities are expected to decrease further in the coming years. However, the projected rate of decrease in concentration is higher than the recently observed rate. Therefore, projections about the expected rate of decrease in the future cannot be made reliably. In 2017, the average concentration of particulate matter in the Netherlands was comparable to 2016. Decreases observed over the past several years appear to have levelled off at present. The number of exceedances for particulate matter increased somewhat compared to the previous year, primarily because more livestock farms were subject to detailed modelling this year. Projected trends in the average concentration of particulate matter in the coming years remain uncertain. The monitoring activities carried out as part of the National Air Quality Cooperation Programme (NSL) provide the basis for these conclusions. Lower concentrations of nitrogen dioxide and particulate matter improve public health, even when they are already below European limit values. Uncertainties and risks Government bodies need to provide updated data on road traffic and livestock farms to facilitate calculations within the framework of the NSL. In recent years, the quality of much of these data has improved substantially. A strong focus on data quality continues to be important for providing a reliable picture of air quality. In various locations, the concentrations of nitrogen dioxide and particulate matter are close to European limit values. Slight increases in the concentrations could strongly affect the number of exceedances. This means the number of exceedances is sensitive to uncertainties in the calculations.
    • Gemeten en berekende concentraties stikstof(di)oxiden en fijnstof in de periode 2010 t/m 2015 (Update) : Een test van de standaardrekenmethoden 1 en 2

      Wesseling, J; Nguyen, L; Hoogerbrugge, R (Rijksinstituut voor Volksgezondheid en Milieu, 2018-12-19)
      Concentraties van stikstofdioxiden en fijnstof die in de lucht langs wegen zijn berekend, liggen in de periode 2010 tot en met 2015 gemiddeld dicht bij concentraties die daar zijn gemeten. De rekenmethoden voor de luchtkwaliteit voldoen ruimschoots aan de eisen in de Europese richtlijnen, en daarmee ook aan de Nederlandse wetgeving. Dit blijkt uit onderzoek van het RIVM waarin reken- en meetresultaten van luchtkwaliteit zijn vergeleken. Dit onderzoek is uitgevoerd voor het ministerie van Infrastructuur en Milieu. Voor zowel stikstofdioxide als voor fijnstof voldoen de modellen ruimschoots aan de eisen die de EU richtlijn aan berekeningen stelt. Overigens kennen zowel metingen als berekeningen onzekerheden van enkele microgrammen. Hoewel het mogelijk is om met berekeningen en metingen de luchtkwaliteit goed in beeld te krijgen en te beoordelen, is het bij de interpretatie belangrijk de onzekerheden te onderkennen. In de onderzochte periode zijn circa 190 gemeten concentraties fijnstof (PM10), zo'n 100 concentraties kleiner fijnstof (PM2,5) en ruim 2300 gemeten concentraties stikstofdioxide vergeleken met de resultaten van de officiële standaardrekenmethoden voor luchtkwaliteit. De conclusies komen nauw overeen met een vergelijkbare analyse van het RIVM uit 2013.
    • 21st EURL-Salmonella interlaboratory comparison study (2016) on typing of Salmonella spp

      Jacobs-Reitsma, WF; Verbruggen, A; Bouw, E; Mooijman, KA (r, 2018-12-18)
      The National Reference Laboratories (NRLs) of all 28 European Union (EU) Member States performed well in the 2016 quality control test on Salmonella typing. Overall, the EU-NRLs were able to assign the correct name to 99% of the strains tested. In addition to the standard method for typing Salmonella (serotyping), fifteen laboratories performed typing at DNA level using Pulsed Field Gel Electrophoresis (PFGE). This more detailed typing method is sometimes needed to trace the source of a contamination. For quality control, participants received another ten strains of Salmonella to be tested by this method. Thirteen of the fifteen participating laboratories were suitably equipped to use the PFGE method. Since 1992, the NRLs of the EU Member States are obliged to participate in annual quality control tests which consist of interlaboratory comparison studies on Salmonella. Each Member State designates a specific laboratory within their national boundaries to be responsible for the detection and identification of Salmonella strains in animals and/or food products. These laboratories are referred to as the National Reference Laboratories (NRLs). The performance of these NRLs in Salmonella typing is assessed annually by testing their ability to identify 20 Salmonella strains. NRLs from countries outside the European Union occasionally participate in these tests on a voluntary basis. The EU-candidate-countries Former Yugoslav Republic of Macedonia and Serbia, and EFTA countries Iceland, Norway and Switzerland took part in the 2016 assessment. The annual interlaboratory comparison study on Salmonella typing is organised by the European Union Reference Laboratory for Salmonella (EURL-Salmonella). The EURL-Salmonella is located at the National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
    • 22nd EURL-Salmonella interlaboratory comparison study (2017) on typing of Salmonella spp

      Jacobs-Reitsma, WF; Verbruggen, A; Bouw, E; Mooijman, KA (Rijksinstituut voor Volksgezondheid en Milieu, 2018-12-18)
      The National Reference Laboratories (NRLs) of all 28 European Union (EU) Member States performed well in the 2017 quality control test on Salmonella typing. Overall, the EU-NRLs were able to assign the correct name to 98% of the strains tested. In addition to the standard method for typing Salmonella (serotyping), fifteen laboratories performed typing at DNA level using Pulsed Field Gel Electrophoresis (PFGE). This more detailed typing method is sometimes needed to trace the source of a contamination. For quality control, participants received another eleven strains of Salmonella to be tested by this method. Eleven of the fifteen participating laboratories were suitably equipped to use the PFGE method. Since 1992, the NRLs of the EU Member States are obliged to participate in annual quality control tests which consist of interlaboratory comparison studies on Salmonella. Each Member State designates a specific laboratory within their national boundaries to be responsible for the detection and identification of Salmonella strains in animals and/or food products. These laboratories are referred to as the National Reference Laboratories (NRLs). The performance of these NRLs in Salmonella typing is assessed annually by testing their ability to identify 20 Salmonella strains. NRLs from countries outside the European Union occasionally participate in these tests on a voluntary basis. The EU-candidate-countries Former Yugoslav Republic of Macedonia and Serbia, EFTA countries Iceland, Norway and Switzerland, and Israel took part in the 2017 assessment. The annual interlaboratory comparison study on Salmonella typing is organised by the European Union Reference Laboratory for Salmonella (EURL-Salmonella). The EURL-Salmonella is located at the National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
    • Kinkhoestvaccinatie van zwangeren en het vaccinatieschema voor hun baby's. Aanpassing gewenst?

      Rots, N (Rijksinstituut voor Volksgezondheid en Milieu, 2018-12-17)
      The pertussis bacteria can cause an infection of the respiratory tract, resulting in severe coughing fits. In very young babies, the respiratory problems can be so serious that they need to be hospitalised and sometimes even die. By vaccinating women against whooping cough during pregnancy, babies are protected immediately after birth. Starting at the end of 2019, the whooping cough vaccination will be offered nationwide to pregnant women. As a result, babies will be protected against whooping cough from birth. The Health Council of the Netherlands is advising the Minister of Health, Welfare and Sport on whether the current schedule for babies will need to be adjusted after the whooping cough vaccination for pregnant women has been introduced. To support this advice, RIVM has provided information on the protective effects of two vaccination schedules on the baby. It not only concerns whooping cough but all diseases against which babies are vaccinated in the first year of life, such as diphtheria, tetanus and polio. When a pregnant woman is vaccinated against whooping cough, she makes antibodies against this pathogen. The mother's antibodies enter the child's blood through the umbilical cord. The mother's antibodies protect the child but also prevent the production of antibodies by the child. They are gradually broken down, which reduces protection, so the child must be protected through vaccination. It is important to find the right time to vaccinate the child. Babies are currently vaccinated three times: when they are two, three and four months old. In the other schedule, they are vaccinated twice: when the baby is three and five months old. With the 3-5 schedule, vaccination starts a month later than with the current 2-3-4 schedule and the period between vaccinations is slightly longer. The number of vaccinations for the baby is then reduced from three to two. This schedule is less burdensome for the baby and less expensive. The available information shows that vaccinations according to a 3-5 schedule - including whooping cough vaccination during pregnancy - provide sufficient protection against the diseases against which babies are vaccinated in the first year of life.
    • Staat van Zoönosen 2017

      Uiterwijk, M; Keur, I; Friesema, I; Rozendaal, H; Holtslag, M; van den Kerkhof, H; Kortbeek, T; Maassen, K (Rijksinstituut voor Volksgezondheid en Milieu, 2018-12-11)
      Zoonotic diseases are infections transmissible between animals and humans. This report is an annual description of zoonotic diseases relevant to the Netherlands. Included are reporting trends of notifiable zoonotic diseases, noteworthy research and case studies. This report also focuses on a specific theme related to zoonotic diseases. This year, the theme is One Health collaboration. Similar to previous years, no noteworthy changes were observed in 2017 with regard to most notifiable zoonotic diseases. Foodborne bacteria (Campylobacter, Listeria monocytogenes, Salmonella and STEC) again make up the largest proportion of zoonotic infections this year. The number of cases of leptospirosis is still high, although last year's decline continues. The number of patients with an orthohantavirus-infection has increased further. In 2016, Brucella canis was observed for the first time in dogs in the Netherlands and again in 2017 several imported dogs tested positive for this bacterium. Besides Chlamydia psittaci, several other zoonotic Chlamydia species exist. From 2013, six Dutch patients were diagnosed with C. caviae pneumonia and in 2017, one with C. felis conjunctivitis. Results from a research project about antibiotic resistance (ESBLAT), show that ESBL-genes are most exchanged between people, instead of between animals and humans. Bacteria containing ESBL-genes are able to produce enzymes that prevent antibiotics from working; the bacteria become resistant. The resistance spreads because the genes can be passed on to other bacteria. The Theme of this year is 'Integrated approach of zoonoses; challenges and applications of One Health collaboration'. To signal, assess and control zoonotic infections, there is a strong need for collaboration between different disciplines, based on the principle of One Health. The central idea of One Health is that humans, animals and the environment are interconnec­ted and influence each other. Described is how the One Health principle has evolved. In addition, two recent outbreaks of zoonoses, Seoul in rats and Brucella canis in dogs, show how One Health cooperation in the Netherlands is organised.
    • Voorbij de brand: Leren van ongevallen bij de brandweer : Resultaten van een pilotonderzoek met Storybuilder

      van Kampen J; Chambon M (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-12-10)
      The work of the fire service can lead to dangerous situations and (near) accidents for firefighters themselves, which can result in injuries. This can happen during their work activities in the event of a fire, during preparatory activities or during training activities. For instance working with a (chain) saw, diving or situations in which hazardous substances are released. To improve the safety of employees, the fire service wants to learn from incidents. RIVM has therefore developed, in cooperation with the fire service, an instrument that can be used by all safety regions to collect and analyse data in a consistent manner. This creates a better collaboration between the safety regions to prevent incidents. Currently, incidents involving fire service personnel are registered separately per safety region. In this study, six safety regions systematically gathered information about 140 (near) accidents and dangerous situations at the fire service. They registered which type of accident (almost) occurred, which safety measures may have failed and which instruments were used. The tool developed in this study is based on Storybuilder, an existing tool for national investigation of occupational accidents for which employers are obliged to notify the labour inspectorate. The aim of this pilot study was the development of the instrument. Not all accidents that occurred in the Netherlands have been included, and the reported accidents are therefore not representative but give an impression. To use the instrument at a national scale, it is desirable to develop it further and carry out additional research. The study also demonstrates that Storybuilder can be adapted to analyse incidents within a specific sector.
    • Tuberculose in Nederland 2017 - Surveillancerapport : inclusief rapportage monitoring van interventies

      Slump E; Blijboom L; Bregman IM; Erkens CGM; van Hunen R; Schimmel HJ; Soolingen D van; de Vries G (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-12-10)
      The number of tuberculosis patients in the Netherlands decreased considerably in 2017, after rises in the two preceding years. There were 787 TB patients reported in 2017, compared to 862 in 2015 and 887 in 2016. Nearly three quarters of the total number of TB patients in the Netherlands come from areas where the incidence of this infectious disease is high, such as Africa and Asia. As in previous years, the largest group of patients came from Eritrea (94), followed by Morocco (73) and Somalia (58). Various factors led to the drop. These include the decreasing influx of immigrants in 2016 and 2017 as well as the falling incidence of tuberculosis in the Dutch population. Tuberculosis is caused by a bacterium and cases must be notified to the Municipal Public Health Services in the patient’s place of residence. The majority of patients (eighty per cent) went to the doctor of their own accord; ten per cent were found by screening high-risk groups and eight per cent by examining people in the surroundings of contagious patients. Detecting and treating infected contacts as early as possible can avoid having more people catch tuberculosis. Tuberculosis may be contagious, for example if it is in the lungs, but this is not necessarily the case. Its most infectious form (open tuberculosis) was observed in a quarter of patients in 2017. This is shown by the figures for 2017. RIVM reports these figures annually in order to monitor the progress of measures for tackling tuberculosis in the Netherlands. The National Tuberculosis Control Plan 2016-2020 was drawn up to that end in 2016. This plan states for example that all TB patients must be offered HIV testing because HIV infection increases the risk of tuberculosis. The percentage of TB patients in the Netherlands who have been tested for HIV rose from 28 in 2008 to 75 in 2017. In 2017, 23 TB patients were infected with HIV. Another of the targets of the National Tuberculosis Control Plan 2016-2020 is that 90 per cent of TB patients should complete their medicinal treatment, i.e. not stopping it too early. This is important because successful treatment involves patients taking a number of medicines at the same time for a long period of time (for six months or more). This objective was achieved in 2016 for patients who were not resistant to the key medicine against tuberculosis (rifampicin). The treatment results for 2017 are not yet known. When the TB bacterium is insensitive to rifampicin, this is known as rifampicin-resistant tuberculosis. A complex and lengthier course of treatment is then required. Over the last five years, the number of such patients in the Netherlands has fluctuated between ten and twenty. There were eleven in 2017.
    • Het amnionmembraan : Een verkenning

      de Vries C; Braakhuis HM (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-30)
      The National Institute for Public Health and the Environment (RIVM) has carried out an exploratory study into new developments and possible risks associated with the use of the so-called amniotic membrane, both in the Netherlands and elsewhere. For decades, the membrane has been used in ophthalmology as a graft to allow damaged corneas to heal. The amniotic membrane is a very thin membrane that is taken from the placenta. Its use is limited in the Netherlands. New developments concerning the amniotic membrane have mainly been described in the international literature. Research has been carried out into repairing damaged tissues by using stem cells obtained from comparable healthy tissue and growing them on amniotic membrane. The membrane with stem cells can then be placed on the damaged tissue. Another development currently being researched is the possibility of using stem cells from the amniotic membrane to repair damage to other tissues, such as muscles. In the Netherlands, amniotic membrane is mainly used to cover damage to the cornea of the eye. The literature reports only a limited number of risks, such as pain, associated with the use of amniotic membrane. As far as is known, in the Netherlands no complications have been reported concerning treatment with amniotic membrane.
    • The National Immunisation Programme in the Netherlands : Surveillance and developments in 2017-2018

      Schurink-Van't Klooster, T M; de Melker HE (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-27)
      In 2017 kregen ongeveer 760.000 kinderen van 0 tot 19 jaar samen 2.140.000 vaccinaties vanuit het Rijksvaccinatieprogramma (RVP). De deelname aan het RVP is hoog onder kinderen jonger dan 10 jaar, ondanks de daling van ongeveer 2 tot 3 procent voor de meeste vaccinaties sinds 2014. Een uitzondering op de hoge deelname is het aantal meisjes dat zich tegen het humaan papillomavirus (HPV) heeft laten vaccineren, dat met 15 procent is gedaald sinds 2016. Het aantal meldingen (1383) van mogelijke bijwerkingen van vaccins in 2017 was lager dan het jaar ervoor (1483). RVP-ziekten Het aantal patiënten met meningokokkenziekte door MenW blijft stijgen, met 80 patiënten in 2017 en 78 tot en met augustus 2018. Daarom is sinds mei 2018 de MenC-vaccinatie op de leeftijd van 14 maanden vervangen door MenACWY-vaccinatie. Het percentage mensen dat aan MenW-ziekte overlijdt is aanzienlijk hoger (17 procent) dan bij andere meningokokken serogroepen. In 2017 was het aantal meldingen van mazelen met 16 gevallen laag, maar wat hoger dan in voorgaande twee jaren. Het aantal meldingen van kinkhoest was in lijn met 2016 (28,7 vergeleken met 32,6 per 10.000). Er overleden drie mensen aan kinkhoest, één jonge zuigeling en twee ouderen. Het aantal meldingen van acute hepatitis B bleef stabiel (0,7 per 100.000 populatie). Ook het aantal mensen dat ziek werd van een type pneumokokkenziekte waartegen het vaccin beschermt, bleef erg laag in 2017/2018. Net als voorgaande waren er in 2017 weinig meldingen van bof (46), Haemophilus influenzae type b (Hib; 46), meningokokken serogroep C (MenC; 9), difterie (4), tetanus (1), rodehond (0) en polio (0). De inwoners van Bonaire, St. Eustatius en Saba zijn overwegend goed beschermd tegen ziekten uit het RVP. Alleen de bescherming tegen mazelen en difterie is voor sommige leeftijdsgroepen niet optimaal. Alertheid is geboden om eventuele patiënten snel op te sporen om te voorkomen dat deze ziekten zich vanuit omliggende landen verspreiden. Daar zijn sinds kort uitbraken gaande. Nieuwe adviezen en besluiten In juli 2018 heeft de minister van Volksgezondheid, Welzijn en Sport (VWS) besloten om de MenACWY-vaccinatie vanaf oktober 2018 uit te bereiden naar 13-14- jarigen; in 2019 komt er een inhaalcampagne voor alle 15-18-jarigen. Ook is besloten om vaccinatie tegen het rotavirus aan te bieden aan risicogroepen en dat kinkhoestvaccinatie voor zwangeren via het RVP wordt georganiseerd door jeugdgezondheidszorg organisaties. De Gezondheidsraad adviseert vaccinatie tegen pneumokokken aan te bieden aan 60-plussers.
    • Geboortezorg in beeld : een nulmeting en de eerste ervaring

      Struijs JN; de Vries EF; van Over HDCA; Over EAB; Baan CA (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-26)
      In Nederland zijn de afgelopen jaren meerdere maatregelen genomen om de kwaliteit van de geboortezorg en de samenwerking tussen de verschillende zorgverleners te verbeteren. Aanleiding waren de relatief hoge sterftecijfers rond geboortes in Nederland. Om de samenwerking tussen zorgaanbieders te verbeteren kunnen alle onderdelen van de geboortezorg sinds 2017 gezamenlijk worden gecontracteerd in één zogenoemd integraal bekostigingscontract. Deze nieuwe bekostiging vraagt om organisatorische veranderingen, waaronder de vorming van een integrale geboortezorg organisatie (igo). Hier zijn de zorgaanbieders zoals verloskundigen, gynaecologen, kraamzorg, en een ziekenhuis in ondergebracht. In de bestaande bekostigingssystematiek vergoeden de zorgverzekeraars de onderdelen van de zorg rondom zwangerschap en geboorte afzonderlijk aan de verschillende zorgaanbieders. Per 1 januari 2017 hebben zes igo’s vrijwillig integrale-bekostigingscontracten gesloten met zorgverzekeraars. Als nulmeting heeft het RIVM de gezondheid, verrichtingen en zorguitgaven van de geboortezorg in kaart gebracht in de periode voorafgaand aan de overstap naar integrale bekostiging (2015-2016). Uit dit onderzoek blijkt dat de uitgaven aan de geboortezorg voor de igo’s in deze periode iets lager lijken te zijn (ongeveer 180 euro per zwangerschap minder) dan in de regio’s die niet zijn overgestapt in 2017. Verder verschillen de igo’s van de overige regio’s, in de periode voorafgaand aan de overstap in de zorg die zij leverden: meer ruggenprikken (25% versus 21%) en minder keizersneden (14% versus 16%)– de beschikbaarheid van ruggenprikken en zo min mogelijk keizersnedes zijn positieve graadmeters voor de kwaliteit van de zorg voor moeder en kind. Wat de gezondheid van moeder en kind betreft zijn er geen verschillen gevonden. De partijen die bij de igo’s zijn betrokken, zijn positief over het integrale tarief. Het levert in hun regio een intensievere, meer gestructureerde samenwerking tussen de zorgverleners op. Ook is de samenwerking minder vrijblijvend dan voorheen. Wel is het een zeer complexe en tijdrovende klus om de integrale bekostiging in te voeren. Specifieke kennis blijft nodig op organisatorisch, fiscaal en financieel vlak. Het RIVM monitort de komende jaren in opdracht van het ministerie van VWS de overgang naar integrale bekostiging in de geboortezorg. In 2020 wordt een eindrapport gepubliceerd, waarvoor de gegevens uit onderliggend onderzoek als nulmeting dienen.
    • Ontwikkelingen in de stikstofdepositie

      Wichink Kruit RJ; van Pul WAJ; DMO; MIL (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-26)
      RIVM has described the composition of the nitrogen that has settled on the surface (soil and plants) in the Netherlands between 2005 and 2016. It has also been reported how RIVM determines this so-called nitrogen deposition. This includes examining the extent to which ammonia contributes to the total nitrogen deposition. Ammonia is an important component of the total deposition of nitrogen. In the period studied, the total nitrogen deposition (N) consisted of two-thirds of ammonia (NH3-N) and one-third of nitrogen oxides (NOx-N). The national average nitrogen deposition in 1990 was more than 2700 moles of nitrogen per hectare. Since then, it has gradually declined to more than 1700 moles of nitrogen per hectare in 2016. The decline has levelled off in recent years. This is partly due to the fact that the ammonia emission no longer declined. According to the 'Emission estimates for air pollutants in the Netherlands - reporting 2017' from the Netherlands Environmental Assessment Agency (PBL) the total emission and therefore the nitrogen deposition will decline further in future. Ammonia emissions are used to calculate its concentrations in the air, and on this basis the ammonia deposition. The calculations are then corrected by the measured concentrations. The calculated ammonia emissions declined over the entire period between 2005 and 2016. The measured ammonia concentration over the same period increased slightly. These contrasting tendencies have been investigated further. Several factors influence the concentrations of ammonia in the air. Since in recent years the air contains less pollutants to which ammonia can bind, such as nitrogen and sulphur oxides, relatively more ammonia remains in the atmosphere. The divergence of trends in the reported emissions and the measured concentrations can therefore partly be explained by the decreased emissions of nitrogen and sulphur oxides. RIVM is currently investigating the emissions to find out whether these provide any explanations for the remaining difference between the reported emissions and the measured concentration of ammonia over the years. This investigation will be completed by the end of 2018.
    • Regio’s in beweging naar een toekomstbestendig gezondheidssysteem : Landelijke Monitor Proeftuinen –reflectie op 5 jaar proeftuinen

      Drewes HW; van Vooren NJE; Steenkamer B; Kemper PF; Hendrikx RJ; KZG; VPZ (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-26)
      In the Netherlands, initiatives have been implemented at the regional level to drive collaboration and create more sustainable healthcare systems. The Triple Aim: improving population health and the quality of care while reducing the cost growth, underpins these initiatives. With the recognition that health and wellbeing cannot be driven by the healthcare sector alone, organisations from different sectors, e.g. healthcare providers, health insurers, patient and public representatives and municipalities, have begun implementing different kinds of collaborative initiatives. The aim of these initiatives is to transition to a ‘health and wellbeing system’. Such initiatives consist of a variety of different interventions at the regional level, including for example, engaging communities, specialists providing care in GP practices, and interoperable data infrastructures. In 2013, the Ministry of Health, Welfare and Sport (VWS) selected nine regions, called the Dutch Monitor Pioneer sites for Population Management, to develop new and sustainable healthcare systems, which would act as an inspiration for the rest of the health system in the Netherlands. Commissioned by VWS, the National Institute for Public Health and the Environment (RIVM) monitored the Pioneer sites from 2013 to 2018 and mapped the pilots’ evolution. Based on this five-year evaluation, the RIVM has generated eight guiding principles for the successful implementation of regional collaborative initiatives. The principles provide guidelines for successfully shaping initiatives’ important aspects including governance, structures, and process. Commonly recurring themes within the principles include e.g. a shared vision, mutual trust, leadership, political support, and a shared data/knowledge infrastructure. The report highlights how the principles can best be implemented to form sustainable health and wellbeing systems. The Pioneer sites that took a step-by-step approach to the eight guiding principles made the most progress towards a sustainable and collaborative health and wellbeing system. All Pioneer sites underestimated the task ahead and found it more difficult than they expected beforehand. This explains why the Pioneer sites made significant gains at the intervention-level, but struggled to make any progress towards regional population health. Larger changes in the healthcare system, including for example the joining of budgets and the sharing of data and knowledge infrastructures, are not yet commonplace. In order to achieve larger scale changes, the collaborating partners will need to feel a greater sense of urgency for change. Regional and national stakeholders will need to support each other during this transition to a health and wellbeing system. Creating sustainable health and wellbeing systems is no small task, but by working together and giving each other the time and space to experiment, more opportunities can be created.
    • Geen relatie tussen veranderingen in organisatorische aspecten met betrekking tot vaccineren binnen de jeugdgezondheidszorg en ontwikkeling in aantal gevaccineerden 2013-2017

      Quee FA; Mollema L; van Vliet JA; de Melker HE; van Lier EA; RVP; EPI (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-22)
      Over recent years, slightly fewer children are getting vaccinated against diseases through the National Immunisation Programme. The drop is stronger for the HPV vaccination that is only offered to girls. No definite explanation has yet been found for this. The National Institute for Public Health (RIVM) has investigated whether organisational changes in youth healthcare services (JGZ) could have affected this; they are responsible for the vaccinations, which are to a large extent given at child health clinics. The investigation showed that there have been both positive and negative organisational changes. No link was found with the fall in the number of vaccinations. About two thirds of youth healthcare organisations took part in this study, which therefore did not obtain a complete picture of the situation in the Netherlands. The message that came from the youth healthcare sector was that parents are coming to child health clinics less often and are seeing utilisation of youth healthcare services as less self-evident. This could be related to declining accessibility of the JGZ for the vaccinations. RIVM therefore created a picture of the organisational changes that have taken place in the youth healthcare sector between 2013 and 2017. Although a number of locations have been closed, average distances to the child health clinics have remained unchanged. The opening hours of the child health clinics have been extended with respect to 2000 (for example in the weekends and evenings as well). The number of children who came to the child health clinics was slightly lower in 2016 than in 2015. The number of visits to child health clinics has also been adjusted on a number of occasions to suit the parents' needs. The four 'contact moments' per year at which vaccinations are given to babies and toddlers have not changed. Moreover, more child health clinics have been sending reminders to parents before the visits. A number of organisations also offer extra information to parents about vaccinations. The JGZ itself considers the main causes to be the increasingly critical attitude among parents, the influence of fake news and reporting in the media, distrust of the governmental authorities and the pharmaceuticals industry, and a perceived lack of urgency because childhood diseases are on the wane.
    • Verkenning van extreem-laagfrequente (ELF) magneetvelden bij verschillende bronnen. : Een aanvulling op eerdere metingen

      Dusseldorp A; Pruppers MJM; van Putten EM; CGM (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-19)
      In 2008/2009, RIVM performed pilot measurements of the ELF magnetic field in the neighbourhood of underground cables, substations, and household appliances. The measurements were made at the request of the Municipal Public Health Services (GGD). In 2017/2018, several supplementary measurements were conducted at the following locations: near chargers of electric cars and bicycles; at substations situated at solar parks; near solar inverters, where direct current is transformed into alternating current; near some additional household appliances. A magnetic field is present if the appliance or installation is switched on, the magnitude being dependent on the source and the distance. The pilot measurements give an impression of the field strength at different distances from these sources. The results should provide the GGD with information on ELF magnetic fields in order to answer questions from the public about sources other than overhead power lines. The Dutch government employs a precautionary policy of not building new homes near overhead power lines in the zone where the annual average magnetic field is stronger than 0.4 microtesla. In April 2018, the Dutch Health Council advised the government to continue this precautionary policy, and to consider expanding it to other possible sources of possible long-term exposure to magnetic fields. This is one of the reasons why people have raised questions about exposure to magnetic field other than those from overhead power lines. It was evaluated at what distance the magnetic field reaches 0,4 microtesla. For chargers of household appliances, this is the case up to a distance of several centimetres from the source; for transformers situated on solar power parks, up to several metres. The annual average value is lower than the measured values. An appliance or installation is not always used (at maximum capacity) and users are not always present near the appliance.
    • Pilot Belevingsthermometer : Peilen van de beleving van veiligheid bij omwonenden van chemische industrie

      Chambon M; Claassen EAM; Folkertsma E; Neuvel JMM; van Vliet AAC; Versluis S; Zonneveld M; MSO; VLH (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-19)
      The Ministry of Infrastructure and Water Management asked RIVM to develop a tool that can be used to gauge how safe persons living near chemical industry feel. A pilot was carried out to develop an initial version of the tool and to test the tool in two cities: one with a great deal of chemical industry in the vicinity (Zaandam), and one with a few chemical companies located in the city (Deventer). The main goal of this project was the development of a new tool. This tool consists of a questionnaire that provides insight into how safe persons living near chemical industry feel with regard to activities involving hazardous substances. The answers also indicate which factors are related with their feeling of safety. The questionnaire turns out to be a suitable tool for gauging feelings of safety. Measurements can also be repeated to reveal trends over time. However, the formulation and order of presentation of the questions can be improved. In addition, to ensure the effectiveness of the method, the sample of participants chosen must be sufficiently representative of the population. Besides the new tool, also some of the results of the questionnaire are presented. The substantive result of the pilot should be considered indicative, as the participants of the pilot did not form a sufficiently representative sample of the residents of the two cities. It might be obvious, however the answers indicate that residents of a city with a few chemical companies feel safer than residents of a city located near a great deal of chemical industry. The factor that is most closely related to the feeling of safety is the degree to which people are positive about their living environment. The more positive the experience of the living environment is, the more positive the feeling of safety is and vice versa. The degree to which people have confidence that government bodies and companies can prevent an accident from happening also relates to the feeling of safety. The more confidence there is, the greater the feeling of safety and vice versa. The same applies to the degree of confidence that emergency assistance services will be able to mitigate the consequences of an accident with hazardous substances. Finally, people also feel safer if they are confident that they can limit the consequences of a possible accident themselves.
    • Kwaliteitscontrole parameters van de Nederlandse Downsyndroom screening laboratoria met de combinatietest, 2017

      Carbo E; EVG; GZB (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-13)
      The first trimester combined test for Down syndrome executed by seven Dutch screening laboratories was in line with the quality requirements in 2017. These are the findings of an assessment by RIVM, meeting the directive of the Dutch Ministry of Health, Welfare and Sport to ensure the quality of the combined test. Since 1 January 2007, screening for Down syndrome with the first trimester combined test has been available to all pregnant women, as part of a nationwide screening programme. Screening for Edwards' syndrome and Patau syndrome was added to the programme later. Starting in April 2017, a new prenatal test, known as the Non-Invasive Prenatal Test (NIPT) has been introduced as another prenatal test in the Netherlands in the TRIDENT-2 study. Due to this new development, many women chose the NIPT over the first trimester combined test. Since December 2017, all laboratories except the Star-SHL laboratory in Rotterdam have stopped analyzing the combined test, due to the reduction of number of participating women. A total of 21,307 screening tests were carried out in 2017, which means that 12.3 per cent of pregnant women opted for the test in 2017. This percentage is an average based on the entire year of 2017, and it should be noted that the NIPT was introduced in April. The percentage of participating pregnant women was 38.9 per cent in the first three months in 2017, while 4.1 per cent of pregnant women participated in December 2017. The laboratories performed all the blood analyses of the first trimester combined test. The complete risk calculation based on the blood analysis and nuchal translucency was carried out by either the laboratories or by some of the ultrasound scanning centres in the Netherlands. The risk calculations for 61 per cent of the total number of combined tests performed in 2017 were made in the laboratories. Part of this evaluation is based only on the probability calculations provided by the laboratories, supplemented by the complete risk calculations supplied by one regional centre (SPSNN). The maternal age at which the test was most frequently conducted in 2017 varied between the laboratories, with median ages ranging from 31.0 to 32.4. The number of pregnant women who had an increased risk of having a child with Down syndrome varied slightly per laboratory (between 3.4 and 6.8 per cent). These differences are a result of, among other things, the average age of the participating pregnant women, which differed slightly from one region to another.
    • Verkenning werkwijze controle en beoordeling grondwaterkwaliteitsdata in LMG, KMG, PMG

      Baumann RA; Claessens JW; Prins HF; LGW; MIL (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-13)
      Three monitoring programmes are used in the Netherlands to collect data on the quality of the groundwater. RIVM operates the National Groundwater Quality Monitoring Network (LMG), while the WFD Groundwater Quality Monitoring Programme (KMG) and the Provincial Groundwater Quality Monitoring Programme (PMG) are operated by the provinces. The groundwater quality data of these programmes are currently being integrated into a single system, the Key Register of the Subsurface (Basisregistratie ondergrond, BRO). It is important that the data are comparable. RIVM has therefore analysed how these data are validated. The validation protocol used by the different organisations, allows some freedom in this respect. . The exploratory study shows that various types of software are used to control and assess the data. Furthermore, the quality control and assessment are carried out by different parties (RIVM, the provinces or a hired party). The way in which the data are ultimately documented also varies. These observations have led to an agreement to develop an automated standard for data control and assessment. It is important that this takes place under the responsibility of the parties delivering the data, that is, the so called source owners. Despite the above differences, it is expected that at least 90% of the data in the three monitoring programmes can be included in the BRO with sufficient quality assurance. Between 5 - 10% of the data need adjustment that can be underpinned by facts. Around 2% of the data will still need some discussion. A panel of experts will have to decide which of these data should be included in the BRO and, if so, how this should be done. It is also crucial that a uniform method is developed for handling of this data.
    • Referentiekader spreiding en beschikbaarheid ambulancezorg 2018

      Kommer GJ; Mulder M; KZG; VPZ (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-08)
      Op basis van ritgegevens over het jaar 2017 heeft het RIVM berekend hoeveel ambulances er in Nederland nodig zijn. Op werkdagen overdag zijn er 614 ambulances nodig, vijf meer dan uit de doorrekening over 2016 bleek. Op werkdagen in de avond zijn drie ambulances meer nodig. De berekeningen wijzen uit dat er in het weekend, op zaterdagen overdag en in de nacht van zaterdag op zondag, twee ambulances minder nodig zijn. Op andere uren van de weekenddagen varieert het aantal extra benodigde ambulances tussen nul en één. De stijging op landelijk niveau van vijf ambulances was minder groot dan in 2016. Toen waren er nog tien ambulances meer nodig ten opzichte van het voorgaande jaar. De afnemende stijging heeft te maken met de relatief lichte groei van het aantal ingezette ambulances in 2017. Het aantal spoedeisende inzetten steeg in 2017 met 0,3 procent ten opzichte van 2016, het aantal inzetten in de planbare ambulancezorg daalde met 0,8 procent. De benodigde capaciteit van de ambulancezorg in Nederland wordt berekend met behulp van een zogeheten referentiekader. Dit kader definieert het aantal ambulances waarmee de ambulancezorg in Nederland kan worden uitgevoerd. Dit gebeurt op basis van een aantal randvoorwaarden, zoals de tijd na een melding waarbinnen een ambulance ter plaatse moet zijn en de spreiding van de standplaatsen over het land. In opdracht van het ministerie van VWS heeft het RIVM het referentiekader in 2018 geactualiseerd met cijfers over het gebruik van ambulancezorg in Nederland in 2017.
    • Gammastralingsniveaumetingen aan de terreingrens van COVRA N.V. te Borsele in 2017 met het MONET-meetnet

      Tanzi CP; ABI; VLH (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-01)
      In 2017, the radiation level in 2017 caused by gamma radiation at the site boundary of the COVRA N.V., the Central Organisation for Radioactive Waste, was below the maximum permitted level of 40 microsievert per year. The maximum measured gamma dose is 3,0 microsievert per year. This is the result of measurements carried out by RIVM. RIVM is tasked by the Authority of Nuclear Safety and Radiation Protection (ANVS) to annually report on whether COVRA N.V. meets the criterion set out in its operating license. COVRA N.V. needs to ensure that the maximum effective dose received by persons outside the boundary of COVRA N.V. does not exceed 40 microsievert annually, as is stipulated in the operating license. In order to determine the maximum effective dose, the gamma radiation is measured at twelve locations along the site boundary. The measurements are carried out within the framework of the MONET monitoring network, which falls under the administrative management of the RIVM. The measurements are analyzed by subtracting the natural background value. The resulting measurement data are corrected with the so-called "Actuele Blootstelling Correctiefactor" (ABC-factor). An ABC-factor takes into account the specific use of the area where the gamma dose may be incurred. This translates into a maximum effective dose of 3.0 microsievert per year, which is far below the maximum permitted yearly gamma dose. In this report the daily averages of the radiation dose recorded by the MONET-monitors at the boundary of COVRA N.V. in 2017 are shown, and an explanation is given of how the background level at each measuring location was determined.