• European critical loads: database, biodiversity and ecosystems at risk : CCE Final Report 2017

      Hettelingh, JP; Posch, M; Slootweg, J (Rijksinstituut voor Volksgezondheid en Milieu, 2017-12-01)
      With this Final Report 2017 the Coordination Centre for Effects (CCE) located at the National Institute for Public Health and the Environment (RIVM, Bilthoven, the Netherlands) is concluding its work. In 1990, tasks of the CCE were offered by the Netherlands to the Convention on Long-range Transboundary Air Pollution (LRTAP Convention) of the United Nations Economic Commission for Europe (UNECE). The LRTAP Convention then adopted the CCE as programme centre of the "International Cooperative Programme for the Modelling and Mapping of Critical Loads and Levels and Air Pollution Effects, Risks and Trends" (ICP M&M) under its Working Group on Effects. The main task of the CCE includes the development of methodologies and databases enabling the assessment of thresholds ("critical loads") for the protection of ecosystems against adverse effects of atmospheric pollutants, with an emphasis on acid and nitrogen depositions. For this task, the CCE collaborates with a European network of National Focal Centres of the ICP M&M. In this context, the CCE is regularly requested by the Convention to issue calls for data to these centres. The CCE is finally responsible for the compilation of national information on critical loads into a European database. The European critical loads database is then used in the Greenhouse Gas Interactions and Synergy Model (GAINS) held by the Centre for Integrated Assessment Modelling of the LRTAP Convention (located at IIASA, Austria) in support of European air pollution abatement policies. In this report, latest results of the CCE are described (Part 1) with special attention for the consolidation of information in a manner that is tailored for use by the - at the time of writing this report not yet identified - successor of the CCE. Part 2 contains detailed accounts of the work conducted by National Focal Centres over the past two years. Chapter 2 focuses on the call for critical loads data 2015-2017. A novel element consisted of requesting National Focal Centres to include methods to compile critical loads for biodiversity, i.e. thresholds of acid and nitrogen deposition below which the loss of specific plant species does not occur according to present knowledge. Consensus on these methods had been achieved under the ICP M&M during a number of preparatory meetings and workshops prior to the 2015-2017 call for data. In addition to these novel critical loads, also data were requested to enable an update of the European critical loads database that had been used in support of LRTAP Convention protocols and the National Emission Ceilings Directive of the European Union. Fourteen Parties to the Convention, i.e. twelve EU Member States plus Switzerland and Norway, submitted critical loads of nitrogen and of sulphur, including seven Parties that also submitted critical loads for biodiversity. It is noted that that the data required for the assessment of critical loads for biodiversity need to be further completed to include more NFC submissions and more nature types. In view of this, a possible improvement of the modelling of relationships between the probability of occurrence of plant species and abiotic conditions is described in Chapter 4. For countries that do not submit data, the CCE developed over the years a so-called European background database, described in Chapter 3, in collaboration with Alterra (the Netherlands). The use of this database enables computed critical loads for acidity, nitrogen and biodiversity to cover ecosystems in the whole of Europe. Thus, critical loads are available for European ecosystems categorized according to the European Nature Information System of the EEA, covering an area between two and three million km2. The updated European database on critical loads, has then been used for the analysis of effects of air pollution abatement alternatives (Chapter 1) to illustrate results of the application of the database in the GAINS model. It turns out that a simulation of abatement policies embedded in the so-called Current Legislation pathway leads to a reduction of the ecosystem areas being at risk of excessive nitrogen deposition from 67 % in 2005 to about 58 % of in 2020. For the EU28 these percentages are 81 % and 71 % respectively. When acidification is used as endpoint a reduction from 11 to 4 percent of areas at risk can be noted between these years. In addition, the impact of climate change on critical loads and exceedances is included in Chapter 1 to illustrate the potential capability of methodologies to assess interactions with effects of air pollution as expressed in the long-term strategy of the Convention. Finally, it is recommended that knowledge of effects of interactions between air pollution and climate change be further strengthened by improving critical loads of biodiversity. This could include various interactions that affect the health of ecosystems, such as between temperature, drought, ozone, nitrogen and aerosol exposure. These assessments could help support multi-effect oriented policies that are jointly framed under UN-Conventions and EU strategies for air pollution, climate and biodiversity. The successor of the Coordination Centre for Effects is encouraged to continue the coordination and programming of this scientific challenge in collaboration with other effect-based programmes under the LRTAP Convention.
    • 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.
    • The National Immunisation Programme in the Netherlands : Surveillance and developments in 2017-2018

      Schurink-van 't Klooster TM; de Melker HE; RVP; I&V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-27)
      In 2017, about 760,000 children aged 0 to 19 years received a total of 2,140,000 vaccinations within the National Immunisation Programme (NIP). Participation in the NIP was high among children under 10 years of age, despite the drop by around 2-3% for most vaccinations since 2014. An exception in the high participation is the number of girls who was vaccinated against human papillomavirus (HPV), which has declined by 15% since 2016. The number of reports (1,383) of possible adverse events following immunisation in 2017 was lower than the number of reports in 2016 (1,483). <br> <br>NIP target diseases<br>There is an ongoing increase in the number of cases with meningococcal serogroup W (MenW) disease with 80 cases reported in 2017 and 78 up to August 2018. Because of this increase, since May 2018, the MenC vaccination given at 14 months of age has been replaced by a quadrivalent MenACWY vaccination. The case fatality of MenW disease (17%) was substantially higher than for other serogroups. <br> <br>In 2017, the number of measles cases was low (16 reported cases) but higher than in the previous two years. The number of pertussis reports in 2017 was comparable with 2016 (28.7 compared with 32.6 per 10,000). Three people died from pertussis, one infant and two elderly. The number of reports of acute hepatitis B infections stayed stable (0.7 per 100,000 population). Also, the incidence of vaccine type invasive pneumococcal disease (IPD) remained very low in 2017/2018. Once again, the number of reported cases were in 2017 low for mumps (46), Haemophilus influenzae type b (Hib; 46), meningococcal serogroep C (MenC; 9), diphtheria (4), tetanus (1), rubella (0) and polio (0). <br> <br>The inhabitants of Bonaire, St. Eustatius and Saba are predominantly well protected against NIP diseases. However, protection against measles and diphtheria is suboptimal for some age groups. Awareness is needed to prevent these diseases from spreading from neighboring countries, where outbreaks currently are observed. <br> <br>New advice and decisions<br>In July 2018, the Ministry of Health, Welfare and Sports decided to expand the MenACWY vaccination outbreak programme to 13-14 year olds. In 2019, there will be a catch up campaign for all 15-18 year olds. Furthermore, it was decided that vaccination against disease caused by rotavirus will be included in the NIP for risk groups, and that maternal pertussis vaccination in the NIP will be organised by youth health care organisations.The Dutch Health Council advises to offer vaccination against pneumococcal disease to the people 60 years and older. <br>
    • Staat van Infectieziekten in Nederland, 2017

      de Gier B; Mooij SH; Hahne SJM; I&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-09-04)
      In 2017, the number of people who fell ill in the Netherlands as a result of meningococcal type W increased sharply once again. In 2017, 80 patients were reported, compared to an average of 4 patients per year before 2015. Because of this increase, from 1 May 2018 the meningococcal C vaccination given to babies of 14 months was replaced by a vaccine that protects against more types of meningococcal bacteria (ACWY). From the autumn of 2018, the meningococcal ACWY vaccine will also be offered to teens born between 2001 and 2004.<br> <br>In addition, it appears that the number of patients with Legionnaires' disease has increased since 2012, from 291 people in 2012 to 561 in 2017. Some of these infections were contracted by Dutch people while travelling abroad. In particular, the number of infections contracted in the Netherlands was higher in 2017 than in previous years, with a peak in the summer months. The cause of the increase is unclear; however, there is a relationship with warm and wet weather. The infectious diseases that caused the most health loss in the Netherlands in 2017 were influenza, pneumococcal disease and legionella disease.<br> <br>These are the findings published in the State of Infectious Diseases of RIVM. This annual report provides policy makers at the Ministry of Health, Welfare and Sport, the municipal health services and RIVM, among others, with an overview of the most important developments in infectious diseases in the Netherlands and abroad.<br> <br>Every year, the State of Infectious Diseases focusses on an in-depth theme. This time, the theme is 'Infectious disease epidemiology in the year 2018'. It discusses what the sharp increase in digital data in recent years means for research into the extent to which infectious diseases occur and into sudden outbreaks of diseases. For example, it is possible to detect outbreaks of diseases earlier because more and more genetic data from pathogens are becoming available. The new data and methods are an important addition to the 'traditional' methods, but cannot replace them. <br>
    • 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; I&amp;V (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. <br> <br>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. <br> <br>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. <br>
    • Stralingsniveaumetingen aan het terrein van de EPZ kerncentrale Borssele in 2017

      Tanzi CP; ABI; M&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-01)
      In 2017, the radiation level caused by gamma radiation at the site boundary of the Borssele nuclear power plant was below the maximum permitted level of 10 microsievert per year. The maximum effective dose is 1.04 microsievert. This is the result of measurements carried out by the RIVM on location. RIVM is tasked by the Authority for Nuclear Safety and Radiation Protection (ANVS) to annually report on whether the Borssele nuclear power plant meets the criterion stipulated in the license. <br> <br>The nuclear power plant needs to ensure that the maximum effective dose received by persons outside the site boundary of Borssele NPP does not exceed 10 microsievert annually. This is stipulated in the operating license, granted in 2016 following the Dutch legislation on the use of nuclear energy. In order to determine the maximum effective dose, the gamma radiation is measured at 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. Around the boundary of the Borssele nuclear power plant the ABC-factor is 0,2. This translates into a maximum effective dose of 1.04 microsievert per year, which is below the maximum permitted yearly gamma dose. <br> <br>From Octobre 2016, the regular network of eight monitors was inoperative due to work activities on the site. In 2017 control measurements of the radiation level were carried out continuously at four temporary locations at the site boundary. In June 2017 the regular network of eight monitors was restored. In this report the daily averages of the radiation dose recorded by the MONET-monitors around the Borssele nuclear power plant and an explanation of how the background level at each measuring location was determined are shown. <br>
    • Antifouling systems for pleasure boats : Overview of current systems and exploration of safer alternatives

      Wezenbeek JM; Moermond CTA; Smit CE; MSP; M&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-10-02)
      Antifouling paints are often used on the surfaces of pleasure boats to prevent the growth of algae and shellfish below the waterline. These paints contain toxic substances. The Dutch government is committed to encouraging boat owners to switch to the use of antifouling systems that are safer and have less environmental impact. The National Institute for Public Health and the Environment (RIVM) has therefore drawn up an overview of current and future possibilities for preventing the fouling of the surfaces of pleasure boats under the waterline. A number of systems are expected to have considerably less impact on the environment than those now in use. RIVM also puts forward suggestions for promoting the use of these cleaner antifouling systems. <br> <br>Existing antifouling paints are often 'self-polishing paints' which contain copper as a biocide and zinc as a co-formulant: the paints wear during sailing, gradually releasing these substances. As a result, heavy metals end up in the water and impact the environment. <br> <br>There are already various systems available for pleasure boats that do not contain biocides, some of which have probably less impact to the environment than the self-polishing paints that do. These include hard 'foul release coatings', other hard coatings, films with flexible plastic fibres that act as spines and systems based on ultra sound. Some promising antifouling systems that, for example, use ultraviolet light or natural, readily degradable biocides that stay in the coating are still in the research phase. <br> <br>RIVM recommends examining the legal possibilities for reducing the use of antifouling systems that contain biocides and self-polishing paints. How well or badly existing possibilities score in the field of antifouling performance, safety and environmental impact should, furthermore, be clearer for consumers. The development of a standardised test that can be used to determine the efficacy of antifouling systems under different conditions is also desirable. <br>
    • Horizon scan of medical technologies : Technologies with an expected impact on the organisation and expenditure of healthcare

      van der Maaden T; de Bruijn ACP; Vonk R; Weda M; Koopmanschap MA; Geertsma RE; EVG; V&amp;Z (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-10-08)
      Medical technology is developing rapidly. Promising new technologies could offer benefits for the quality and organisation of healthcare. However, in practice innovations do not always fully match with medical and societal needs. Healthcare professionals, patients, health insurers, industry and the authorities all agree it is important to improve this. To achieve this, it is important that relevant stakeholders start to join forces already in early stages of development. This is a message from a 'horizon scan' of medical technologies performed by the RIVM at the request of the Dutch Ministry of Health, Welfare and Sports. <br> <br>The 'horizon scan' identifies technologies with a potentially major impact on the society. eHealth, robotics to support care for the elderly, and the 3D printing of for example implants or of organ models to be used for the preparation of surgery, may offer major potential benefits. These technologies are expected to affect the organisation and costs of care, either in a positive or negative sense. The precise impact of these technologies is difficult to predict. <br> <br>Other technologies may also have major impact. Nanotechnology, for example, is considered a technology that enables other innovative developments, such as early diagnosis and treatment of cancer; personalised medicine (customized care) as a development that is enabled by promising medical technologies. In addition, non-medical technologies such as 'big data' and artificial intelligence can have major impact on healthcare. <br> <br>Bringing together stakeholders is the first, important, step to better connect technological possibilities with medical and societal needs. This may provide direction to developers of technology. It can also help healthcare organisations to take full advantage of promising medical technology. <br>
    • Het gebruik van biomonitoring en sensoring binnen de arbeidsomstandigheden - praktische en ethische overwegingen

      Krom A; ter Burg W; van de Weijgert VPL; Palmen NGM; NAT; M&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-09-04)
      To ensure the safety of workers the exposure to chemical substances should be as low as reasonably possible. There are several ways to measure the exposure. Two promising techniques that could complement current measuring techniques are biomonitoring, to assess internal exposure, and sensoring, to assess external exposure. Information acquired through these methods can be used for worker health protection. Careful application of these techniques is important. This also includes considerations on dealing with private information under privacy law and whether workers should be able to decide for themselves to join measurement campaigns. The balance between pros and cons should be beneficial for the worker. To create a positive balance, it is crucial that the measurement data are indeed used to protect the worker. <br> <br>This is based on the RIVM research that lists the pros and cons of these techniques with respect to both practical and ethical aspects. The information gathered serves as background information to support discussions within the Social and Economic Council of the Netherlands (SER) about the question whether or not to apply these techniques more prominently in the Netherlands. The report describes how effective biomonitoring and sensoring are (and to what aim), and the extent to which exposure measurements can be intrusive, for instance concerning bodily integrity. In addition, the report addresses the rights, duties and responsibilities of key-actors, such as employers, employees, and health and safety workers (physicians and occupational hygienists). They have a shared responsibility to determine if the exposure measurements and exposure reduction measures are proportional to the goals at hand. <br> <br>Biomonitoring is used to determine substances in bodily fluids, such as blood or urine, as a measure for exposure. On a small scale it is used in the Netherlands and more often across Europe and in the United States of America. Biomonitoring is very useful for those substances that are difficult to measure in the air or if dermal exposure is the main route of exposure. A disadvantage is that bodily fluids are required. Furthermore, the number of substances for which measurement protocols and biological limit values exist is limited. <br> <br>Sensoring is used to measure substances using small electronic devices (sensors). The advantages are that the devices provide real-time results and are easy and light weight to wear. A disadvantage is that the measurements are difficult to relate to specific activities of the worker. Also, they are not yet suitable to test exposure to limit values. <br>
    • Inventarisatie mogelijke bestaande blootstellingssituaties in Nederland : Onderzoek voor de implementatie van richtlijn 2013/59/Euratom

      van der Schaaf M; Folkertsma E; Valk D; M&amp;M; M&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-10-04)
      RIVM has carried out a survey of situations in which people are (amenable to be) exposed to ionising radiation that have not been subject to radiation protection legislation, but are so since 6 February 2018. These situations are called 'existing exposure situations'. The survey is a first step for possible policy development on this matter. Existing exposure situations do not encompass situations that already are under regulatory control of the competent regulatory authorities, as for instance is the case for nuclear power plants and radiation generators. <br> <br>Since 6 February 2018, new European radiation protection legislation requires member states to identify existing exposure situations. These requirements are implemented in the Dutch Decree on Basic Safety Standards for Radiation Protection ("Bbs"). Of the 24 situations identified in the survey, 15 are considered as possible existing exposure situations. The remaining 9 situations are situations that are excluded from regulation, or situations that appeared to be under regulatory control ('planned exposure situations'). <br> <br>The exposure to radon and thoron and exposure to external radiation in buildings are possible existing exposure situations. Taken together, these situations account for a dose of approximately 1 millisievert per year for an average member of the population. This corresponds with approximately 40% of the total average annual exposure to ionising radiation in the Netherlands. An dose of 1 millisievert per year is relatively low in comparison to the 'reference levels', as laid down in European legislation, which should range between 1 and 20 millisievert per year. The exposure in the remaining 12 situations is much lower and is also of a more local nature. <br> <br>The survey was carried out at the request of the Authority for Nuclear Safety and Radiation Protection (ANVS).<br>
    • Rotavirus in the Netherlands : Background information for the Health Council

      Verberk JDM; Bruijning-Verhagen P; de Melker H; RVP; I&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2017-04-06)
      Rotavirus can cause a gastrointestinal infection and is common in young children. There are two vaccines available; both have to be administered via the mouth. The Dutch Health Council will advise the Ministry of Health, Welfare and Sport on how childhood vaccination against rotavirus will be made available. The Minister makes a decision on the basis of this advice.<br> <br>To support the Health Council, the RIVM has put together background information on rotavirus disease. The information includes the number of people in the Netherlands that become ill from rotavirus every year, the effectiveness and safety of rotavirus vaccines, and how the public thinks about rotavirus vaccination.<br> <br>A gastrointestinal infection caused by rotavirus is common during the winter months, particularly in children between six months and two years old. The disease is characterized by fever, vomiting and diarrhoea. Usually, rotavirus disease resolves by itself without problems, but can be severe resulting in dehydration. This happens more often in young children, premature children, children with low birth weight and children with congenital problems. These severe cases may need to be admitted to the hospital. Treatment for dehydration consists of oral or intravenous rehydration. In rare cases, a child dies.<br>
    • Disease burden of food-related pathogens in the Netherlands, 2017

      Mangen MJ; Friesema IHM; Pijnacker R; Mughini Gras L; van Pelt W; SIS; I&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-07-04)
      The Ministry of VWS has requested RIVM to present an annual update on the number of illnesses, disease burden and cost-of-illness caused by 14 enteric pathogens. These pathogens can be transmitted by food, the environment, animals and humans. The disease burden is expressed in DALYs (Disability Adjusted Life Years), a metric integrating morbidity and mortality into one unit. Furthermore, the cost-of-illness (COI) related to the 14 food-related pathogens was estimated and expressed in euros. The COI estimate includes healthcare costs, the costs for the patient and / or his family, such as travel expenses, as well as costs in other sectors, for example due to productivity losses. The total disease burden caused by the 14 pathogens decreased slightly from around 12,000 DALYs in 2016 to 11,000 DALYs in 2017. The share of foodborne transmission in this estimated burden was comparable with earlier years, mounting to 4,200 DALYs in 2017. The total COI caused by the 14 pathogens decreased slightly from 436 M in 2016 to 391 M in 2017. The food-related COI was with 163 M in 2017, which is slightly lower than in 2016 (i.e. 173 M). The differences in DALYs and COI between 2016 and 2017 are largely due to fluctuations in the type of infections that occur, the burden of disease they cause and the varying costs per infection. <br> <br>The research presented in this report results in more insight in the number of incident cases of foodborne diseases and the associated disease burden and costs-of-illness and enables researchers and policy-makers to monitor trends in time for these 14 pathogens. <br>
    • Study on methodology to perform an environmental noise and health assessment - a guidance document for local authorities in Europe.

      van Kamp I; Schreckenberg D; van Kempen EEMM; Basner M; Brown AL; Clark C; Houthuijs DJM; Breugelmans ORP; van Beek AJ; Janssen-Stelder BM; M&amp;G; M&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-10-29)
      The Environmental Noise Directive (END) is for local authorities the most important instrument to determine the levels of noise pollution. Also, the Directive is aimed at the evaluation of effect of measures and can make the effects of alternative measures visible. The Directive stimulates the Member States to take action to reduce the adverse effects of environmental noise . <br> <br>Annex III of the Directive is currently under revision and will include a method to calculate the effects of different noise sources, such as road- and rail traffic, according to the latest scientific evidence. In preparation of this update, RIVM in collaboration with international partners has prepared a guidance document. Not only annoyance and sleep disturbance are addressed as health effects, but also cardiovascular effects and cognitive impact in children (comprehensive reading impairment). The document is worded in such a way that it is easily used by local authorities. The guidance document was prepared on request of the EU commission. <br> <br>The document describes the steps of a health impact assessment one by one and explains the accompanying decisions and conditions. Next, the actual calculation methods are further explained for two indicators: the number of healthy life years adjusted for disease, disability and death (DALY) and the number of people that experiences adverse effects of noise ((NafP). Finally, as an example, the health impact of noise in Düsseldorf is described. <br>
    • Jaarverslag Bureau REACH 2017 : Grip op chemische stoffen

      Beekman M; Zweers P; van Goor-gras J; ICH; M&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-10-01)
      Chemical substances are everywhere in our society, like plasticizers in polymers, flame-retardants in matrasses and solvents in paints. European legislation guarantees the safe production and use of these substances. The two main regulations in Europe are: REACH (registration, evaluation, authorization and restriction of chemicals) and CLP (classification, labelling and packaging of substances and mixtures). <br> <br>On behalf of the Ministries I&M, VWS and SZW, RIVM Bureau REACH supports and provides advice to the European Chemical Agency (ECHA) and (member state) competent authorities on the implementation of this European legislation. This annual report describes the main activities in 2017 and highlights some specific cases. In 2017 Bureau REACH put many efforts in possible new substances of concern in drinking water (like GenX) and the risks related to combined exposure of different substances. <br> <br>If during a risk assessment questions remain, Bureau REACH can ask a producer or importer additional information on the properties of a substance. The outcome of the risk assessment determines if a substance can be identified as a substance of very high concern. In addition, Bureau REACH can propose a harmonized classification based on hazards as established within Europe (according to CLP). With such a dossier it is prescribed how to label a product as soon as the substance is present above the concentration limit value. Furthermore, Bureau REACH assesses dossiers prepared by other Member States and by industry.<br>
    • Publieksperceptie van Stralingsrisico&apos;s: Betekenis voor Risicocommunicatie

      Claassen L; Kerckhoffs T; MNS; M&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-10-26)
      The general public's perception of the risks of a radiation accident is very different from that of experts. While both groups estimate the likelihood of a serious accident taking place to be very small, many civilians, unlike the experts, expect a nuclear accident to cause large numbers of fatalities and deformities, even if takes place far away. This difference in perception occurs because the general public's risk judgements are based on different factors than those considered by the experts, who rely mainly on information of a technical nature. For effective communication about radiation risks, it is important to adapt any information provided to conform more closely to what people already know and think. <br> <br>Four factors influence the way the public perceives risk. First, there is the extent to which the risk is unknown and dreaded. When people are not familiar with a risk and are afraid of it, they are more likely to perceive it as being large. Efforts made to communicate the risks of radiation should, therefore, be aimed at enhancing knowledge amongst the general public about, for instance, the functioning of nuclear installations. <br> <br>Second, people construct a mental 'picture' (knowledge, ideas and images) of the risks of a nuclear accident based on their personal circumstances and experience. By comparing this picture with that of radiation experts, one can find out where the largest differences exist; communication can then be aimed specifically at these subjects. A previous comparison of mental pictures showed that what the Dutch general public really needed was information on what measures they could take if a radiation-related accident occurred, and the location of the nuclear installations. <br> <br>A third factor determining the perception of risk is the attitude that the public holds of a particular activity. This attitude is more positive when people experience benefits associated with it and have confidence in regulatory and supervisory bodies. In order to maintain trust in these institutions, their communication should be transparent and factual. One particular challenge is that scientific information is often open to multiple interpretations, not necessarily in line with the institution's own. <br> <br>Finally, signals which originate in the individual's social environment are also an important factor. These might be signals people pick up from friends or social media. Thus it is important for institutions to use these social media channels to communicate with the public as long as they ensure that they have a well-designed social media strategy which takes into account what people already think and know; they also need to be fully versed in all the challenges of social media use.The public perception of radiation risks: implications for communicating to the public. <br>
    • Geboortezorg in beeld : een nulmeting en eerste ervaringen met het werken met integrale bekostiging

      Struijs JN; de Vries EF; van Dorst HDCA; Over EAB; Baan CA; KZG; V&amp;Z (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-11-26)
      In recent years, various policies have been implemented to improve quality of maternity care and collaboration between maternity care providers aiming to lower the relatively high mortality rates in the Netherlands. Currently, within the existing payment model, providers are paid on a fee-for-service basis. In 2017, a voluntary payment reform was implemented to enhance the collaboration between care providers. The new payment model, a bundled payment model, includes all antenatal and perinatal care services delivered by midwives, obstetricians and maternity care assistance providers. The bundled payment model leads to a new provider-led entity, the integrated maternity care organization (imco) in which community midwives, obstetricians, a hospital and in most cases maternity care assistance providers (in Dutch: kraamzorgorganisaties) participate. <br> <br>Per 1 January 2017, six imco's have signed a bundled payment contract. We performed a baseline measurement in which we examined whether these six regions differed in terms of health outcomes, utilization and medical spending from the other regions in the period before the introduction of the bundled payments. This study showed that - corrected for case-mix - the six regions that have adopted the bundled payment model had lower birth care spending levels as compared to the other regions in the years before the implementation of the bundled payment model. On average the regions had about 180 (3.5%) lower expenditures per pregnancy in 2015 and 2016. Furthermore, future imco's executed more epidurals (25% vs. 21%), yet less C-sections (14% vs. 16%). No differences in health outcomes were observed. <br> <br>In interviews, all maternity care providers and managers reported a positive attitude towards working with the bundled payments model. The bundled payment has led to a more intense, more structured and less informal collaboration between the different providers in their region. The interviewees mentioned that the implementation was complex and time-consuming and there still is a need for in-depth knowledge regarding governance, taxes and finance. <br> <br>In the coming years, the National Institute for Public Health and the Environment will monitor developments regarding payment models for maternity care. A final report will be published in 2020. <br>
    • Geluidmonitor 2017 : Meting en validatie van geluidproductie door rijkswegen en spoorwegen

      Bergmans D; Haaima M; den Hollander H; LKG; M&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-10-29)
      Every year the motorway and railway authorities - Rijkswaterstaat and ProRail - are required to calculate the noise generated by road and railway traffic. RIVM validates these yearly noise calculations by taking their own measurement samples and comparing them with those calculated by the road and rail authorities. Both the above activities fall under the Environmental Management Act.<br> <br>Validation 2016<br>In 2016, on average, the noise produced along national motorways was 2 decibels higher than the calculated values; along railways noise levels agreed with the calculated values. This overall picture is consistent with the findings of previous noise monitoring exercises conducted in 2013, 2014 and 2015.<br> <br>On individual trajectories, the differences between calculation and measurement results varied. For national motorways, the distribution ranged from 2 decibels below to 6 decibels above the calculated levels; for railways, it ranged from 4 decibels below to 6 decibels above.<br> <br>Measurements 2017<br>This report also presents the measurement results for 2017 which, in due course, will be compared to the calculation results set down in the noise monitor 2018. The motorway and railway authorities publish these 2017 results during the second term of 2018. A comparison, therefore, can only be made after this date. <br>
    • Carbapenemase-producerende Enterobacteriaceae (CPE) in ziekenhuisafvalwater

      Schmitt H; Blaak H; Kemper MA; de Rijk SE; van de Schans M; de Roda Husman AM; MLU; I&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-10-30)
      Carbapenemase-producing Enterobacteriaceae (CPE) can cause infections that are difficult to treat with the commonly used antibiotics. They are therefore a threat to public health. Accordingly, it's important to ensure that these resistant bacteria do not spread further in human beings and in the environment. <br> <br>RIVM has investigated whether it would make sense to treat hospital waste water in order to combat the spread of CPE in the environment. However, it turns out that hospital waste water contains only a small fraction of all the CPE bacteria that end up in surface water via waste water. This measure would therefore not substantially reduce the number of CPE that enter the environment. <br> <br>Antibiotic-resistant bacteria end up in waste water treatment facilities via human faeces from hospitals and from the general population. As they are not completely removed there, they then end up in surface water. For this investigation, the waste water from five hospitals and the associated waste water treatment facilities was analysed during 24 hours. The quantity of CPE found varied greatly over time. Generally, less than 10% of the total amount of CPE in the waste water treatment facilities comes from hospital waste water. For some hospitals (one third of the measurements), these numbers can increase to 10 to 60% at certain moments. It was also found that only a small part of antibiotic residues originates in hospital waste water. <br>
    • Marktontwikkeling en leveringszekerheid voor medische isotopen : Uitbreiding op RIVM Rapport 2017-0063: Productie en gebruik van medische radio-isotopen in Nederland. Huidige situatie en toekomstverkenning

      Roobol LP; de Waard IR; M&amp;M; N&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-04-26)
      Radioactive substances can be used for making a diagnosis. There are also radioactive substances that can treat various sorts of cancer, the so-called therapeutic radio-isotopes. Most of these medical isotopes are made in Europe, in six nuclear reactors, one of which is located in the Netherlands (Petten). All but one reactor are advanced in age and sooner or later they will have to be closed. If only one reactor were to close, there could already be shortages in the supply. It is likely that the existing reactors cannot absorb the increased demand, if one of them would close. This makes the guaranteed supply for the world (and therefore also for the Netherlands), rather unsure.<br> <br>RIVM has done research on the guaranteed supply of both diagnostic and therapeutic isotopes for the Netherlands. This depends on various factors, one of them is the available reactor production capacity. The existing reactor in Germany, the youngest in Europe, has research as its main goal, but it could provide a small part of the demand, should one or more reactors have to close. Also, initiatives are taken to build new reactors. In France, a new one is being built, but it will not produce isotopes before 2022. Also, it is still uncertain which therapy isotopes they will produce, and in which quantities.<br> <br>Another factor is the demand for medical isotopes. Also here it is necessary to make a distinction between diagnostic and therapeutic isotopes. The demand for diagnostic scans is projected to grow with 5 to 8 per cent per year. The growth will occur in Asia in particular, because of the rising standards in healthcare there. The growth in turnover of therapeutic isotopes will be many times higher than that. There are no good analyses available to determine how much higher exactly. In the long term, the supply of therapeutic isotopes will not be guaranteed, because most reactors that are producing them are old. It is advisable to make a thorough analysis of when shortages might arise.<br> <br>Finally, the sort of isotope is of influence. In time, isotopes used for diagnoses (molybdenum-99/technetium-99m) could also be produced by means of particle accelerators. The advantage of producing them in this way is that it produces little radioactive waste. Whether hospitals would be inclined to buy this product, depends amongst others on the ratio between price and quality, and whether it is certain that the supply is sufficient. To produce molybdenum-99/technetium-99m without government support, it is necessary to make a transition to full cost recovery.<br> <br>This research is a complement to an earlier report by RIVM about the current state and projected future of medical isotopes in the Netherlands (July 2017).<br>
    • Risicobeoordeling 42 opkomende stoffen in oppervlaktewaterbronnen voor drinkwaterbereiding : Probleemstoffen op basis van Protocol monitoring en toetsing drinkwaterbronnen KRW

      van Leerdam RC; Janssen PJCM; van der Aa NGFM; Versteegh JFM; DDB; M&amp;V (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2018-09-11)
      This report contains an erratum d.d. 16-10-2018 on page 97<br> <br>To ensure that drinking water remains clean, water managers and drinking water companies monitor whether 'new' pollutants are present in the surface water. These substances are called 'new' because they are newly found contaminants for which there is no legal standard yet. To ensure that these substances are detected in surface water at an early stage, it is monitored if the concentration exceeds the signalling value of 0.1 micrograms per litre. If this is the case, the substance's potential health risks are further investigated. From 2013 to 2015, 42 substances appear to have exceeded this signalling value in surface water used for the drinking water supply. Research by the RIVM shows that they do not pose a health risk via drinking water. <br> <br>The 42 researched substances include pesticides, medicine residues, sweeteners and industrial substances. They have ended up in surface water via discharges from industry, the sewage treatment plant or via agriculture. Most of these substances are not completely removed with a simple surface water purification process. <br> <br>In order to identify potential health risks, the RIVM has set up 'provisional guideline values for drinking water' for these new substances - if they did not already exist. These are the concentrations at which the water is still safe to drink. These target values are not laid down by law but serve as a health guideline. In this study, the provisional guideline values were compared with the highest concentrations of the 42 substances found in the surface water sources for drinking water. For each substance, the measured concentration remained well below the provisional guideline value; for most substances with more than a factor of 10. <br> <br>This risk assessment was carried out for the Ministry of Infrastructure and Water Management (IenW) to support the assessment of the targets in the Water Framework Directive (WFD). <br>