As in previous years, the participation for the different vaccinations included in the National Immunisation Programme (NIP) is with 92 to 99 per cent high in report year 2015. Exception is the HPV vaccination against cervical cancer, for which the participation continued to increase compared to report year 2014 (to 61 per cent). The participation for hepatitis B vaccination for children born in 2012, the first year in which all infants were eligible for hepatitis B vaccination, is 94 per cent. The participation among infants from the Caribbean Netherlands for the DTaP-IPV, MMR and pneumococcal vaccination is also high. The participation for MMR vaccination for 9-year-olds (93 per cent) is identical to participation for DTaP vaccination this time; usually participation for MMR vaccination is slightly lower. This is an improvement but the required participation is not reached. A participation of at least 95 per cent is important because of the aim of the World Health Organization (WHO) to eliminate measles worldwide. Such a high vaccination is important to protect the general population against outbreaks (herd immunity). To protect infants effectively against diseases of the NIP it is also important to give vaccinations on time. The proportion of infants that received the first DTaP-IPV vaccination on time, i.e. before they are 10 weeks old, increased further to 89 per cent. In addition, the timely and full participation in the primary DTaP-IPV series (the first three vaccinations) improved from 60 per cent for children born in 2007 to 69 per cent for children born in 2012. With voluntary vaccination, a high vaccination coverage is reached in the Netherlands.

Fresh produce such as fruit and vegetables are treated during production to decrease the numbers of harmful microorganisms. This will extend the produce's shelf life and will reduce the numbers of pathogenic microorganisms on the food. These treatments are especially effective for the inactivation of bacteria, thereby reducing the risk of consumers becoming ill. However, viruses are not efficiently inactivated when treatment is performed with the doses currently used in the food industry. Higher doses may be more effective but adversely affect the quality, color and texture of the product. This has emerged from a literature review conducted by the National Institute for Public Health and the Environment (RIVM) on the effectiveness of disinfection processes for viruses in the food industry. The study was commissioned by the Dutch Food and Consumer Product Safety Authority (NVWA). One of the possible treatments is the washing of produce in water containing disinfectants, such as chlorine compounds, hydrogen peroxide or ozone. Other treatments that are applied on a small scale, such as treatment by UV or gamma rays or high-pressure processing, have the advantage that they not only affect the surface of produce but penetrate the produce to inactivate pathogens sheltered in e.g. crevices or seed pockets. However, they are most effective at doses that induce undesirable structural changes and deteriorate food quality. A promising solution is a combination of treatments ('hurdle technology'). This enables each treatment to be applied at low intensity, thus preserving the freshness and structure of produce but giving it a longer shelf life. The selection of hurdles needs to be made carefully to obtain effective virus inactivation while preserving the quality of the fresh produce.

In 2015, nearly 770,000 children aged 0 to 19 years received a total of 1,547,000 vaccinations within the National Immunisation Programme (NIP). Participation in the NIP, which was between 92% and 99% (depending on the vaccination), was still high. An exception was vaccination against human papillomavirus (HPV), which was 61%. The participation of newborns dropped by about 0.5% for the second consecutive year. Notifications of NIP target diseases The number of reported cases of most NIP target diseases was again low. This was also true for the number of reported measles cases (7) after the great epidemic in 2013/2014. Pertussis was less frequently reported in 2015 (39 per 100,000) than in the epidemic year 2014 (55 per 100,000). One infant death due to pertussis was reported. The incidence of cases of invasive pneumococcal disease - caused by the three additional types which were included in the pneumococcal vaccine in 2011 - was very low in children under 5 years (0.5 per 100,000), and a decrease was seen in other age groups due to herd protection. In 2015 and the first half of 2016, mumps was more common than in 2014 (n=89, n=45 and n=40, respectively). Notifications of adverse events following immunisation In 2015, an increased number of reports of possible side effects of vaccines was reported (1,494 versus 982 in 2014). These were mainly reports of (pronounced) local inflammation and fever in 4-year-olds. The number of reports of fatigue in 12-year-old girls increased after media attention on possible side effects of the HPV vaccination. The severity of the reported adverse events was comparable with previous years. Notifications of potential NIP target diseases In 2015 and 2016, the number of invasive meningococcal serogroup W (MenW) cases increased; these were mostly in people aged 65 years or older. After the extremely low number of cases in 2014, 2015 had an average rotavirus season with the peak in March. Until June 2016, the number of cases of rotavirus was also low, with a later start of the season than usual.

After many years of decrease, the number of tuberculosis patients in the Netherlands rose again in 2015 by 6 percent. In that year, 867 TB patients were reported in the Netherlands, compared to 814 in 2014. The causes are the increased influx of asylum seekers from countries where the incidence of TB is high, and a somewhat higher number of native Dutch people with tuberculosis in 2015. This is shown by the figures for 2015. The RIVM reports these figures every year, in accordance with the WHO's aim to eliminate tuberculosis worldwide. Tuberculosis is a notifiable infectious disease that is caused by a bacterium. Tuberculosis may be contagious, for example if it is in the lungs, but this is not necessarily so. The contagious form of tuberculosis (open tuberculosis) was seen in a quarter of patients in 2015. Nearly three quarters (72 percent) of the total number of tuberculosis patients in the Netherlands originate from areas where the incidence of this infectious disease is high, such as parts of Africa and Asia. In 2015, the largest group of patients originated from Eritrea and Ethiopia. Tuberculosis and HIV An HIV infection increases the risk of tuberculosis, and tuberculosis is often the first sign of an HIV infection. It is therefore important to identify and treat an HIV infection at the earliest possible stage. With regard to a large number of TB patients, it is not known whether or not they are infected with HIV. The percentage of TB patients tested for HIV increased from 28 in 2008 to 60 in 2015, but it is still lower than the 80 percent advised by the WHO. Result of the Treatment As a treatment, the patients must take different medicines at the same time for a longer period of time (often for six months or more). Out of the TB patients in 2014 without any form of resistance against the medicines taken and in respect of whom the treatment results were reported, 88 percent completed the treatment with success. This is slightly less than in 2013 (91 percent). For 5 percent, the treatment results have not yet been reported. The treatment results for 2015 are not yet known.

Industrial plants and cattle farms use scrubber units to remove inorganic or organic substances, gasses or odours from air or gas. In theory, certain conditions of temperature and pH can favour the growth of Legionella in some types of wet air and gas scrubbers. If water droplets can leave the scrubber system, there is a possibility that Legionella will be able to spread to the environment. Further research is needed to determine if this can occur in practice. These facts were revealed by a literature survey and interviews performed by the Dutch National Institute for Public Health and the Environment (RIVM) in response to questions from municipal health services and environmental services on possible health risks to people living in the vicinity of wet air or gas scrubber units due to the spread of Legionella bacteria from such units. These scrubbers remove unwanted substances from air or gas by treating it with fine water spray. Certain chemicals or bacteria may be added to the water in some types of scrubbers (e.g. acidic, caustic and bioscrubbers), and the scrubber water is often collected and reused. Legionella can grow in water if it has a neutral pH and a temperature of between 20°C and 50°C, even for relatively short periods. Dust scrubbers, bioscrubbers and biofilters use water at a neutral pH, and the temperature may rise to within the 20-50°C range for example due to heating by nearby equipment or due to high ambient temperature. Legionella are unlikely to grow in acidic air scrubbers with a pH below 4 or caustic air scrubbers with a pH above 9. About 90 per cent of the roughly 1,500 air scrubber units used in Dutch cattle husbandry is of the acidic type, with a pH of 4 or less, which are unlikely to represent a health hazard. The remaining 10 per cent consists of mainly bioscrubbers, which use bacteria to remove undesirable substances. Growth of Legionella in scrubbers of this kind cannot be excluded if their water temperature rises to above 20°C. The bioscrubbers and dust scrubbers used in Dutch industry could also act as sources of Legionella. From the literature survey and interviews it was not possible to determine how many of these types of air scrubbers are used in the various branches of industry. This report serves as guidance for municipal health services and environmental services to answer questions about Legionella risks of air scrubbers.

It was investigated whether living near livestock farms can affect the health of local residents. The study revealed a number of positive and a number of negative effects of living in the proximity of livestock farms. Therefore, it is not possible to provide a clear-cut answer. People who live around livestock farms were found to have less asthma and allergies than people who live farther away. Among those living close to livestock farms the study found there were fewer people with COPD, a chronic lung disease. On the other hand, people who did have COPD often had more frequent and/or more serious complications of the disease. In addition, a link was found between living near livestock farms and a reduced lung function. This is probably due to substances originating from livestock farms. Living nearby many livestock farms is not the only cause of a reduced lung function. Throughout the studied area it was found that a reduced lung function occurred at times when there was a high concentration of ammonia (a substance originating from manure) in the air. These effects are comparable with the harmful health effects caused by city traffic. The researchers found that there were more instances of pneumonia in the studied area than in the rest of the country, although the difference has decreased since the Q fever epidemic of 2007-2010. A link was found between poultry farms within one kilometre of a home and a slightly higher risk of pneumonia. It is unclear whether the extra instances of pneumonia in the studied area are caused by specific pathogens that originate from animals (zoonotic agents), or by people becoming more susceptible to pneumonia through exposure to substances emitted by livestock farms, such as particulate matter, endotoxins (elements of microorganisms) and ammonia. The study further examined whether certain zoonotic agents occur more frequently in the vicinity of livestock farms than in the rest of the country. This was not the case as regards the hepatitis E virus, the Clostridium difficile bacterium and ESBL producing bacteria. However, people appear to be the carrier of the livestock-related MRSA bacterium slightly more often. It remains unclear whether this increase is due to emissions caused by livestock farms. These are the main conclusions from research carried out by the Dutch National Institute for Public Health and the Environment (RIVM), Utrecht University (IRAS), Wageningen UR and the Netherlands institute for health services research (NIVEL) into livestock farming and the health of local residents. The study was conducted in the eastern part of North Brabant province and in the north of Limburg province. Some results might apply only to the studied area. This is because the findings are influenced by local features, such as air pollution from surrounding industrial areas.

Analysis of poliosamples after accidental release September 2nd, 2014, the vaccine production facility of GlaxoSmithKline (GSK), Rixensart, Belgium, accidentally released 45 liters concentrated poliovirus into the sewage system. After the sewage treatment plant (STP) this water was released into the river Lasne, and subsequently into the Westerschelde. No poliovirus was detected in the samples available and no poliovirus spreading was found in two communities in Zeeland with low vaccination coverage. This was shown a study by the WHO accredited reference laboratory for polio at the RIVM. This research was conducted in The Netherlands as required by the WHO since Belgium does not have a WHO accredited laboratory for the analysis of poliovirus in environmental samples. WHO aims to eradicate polio. The research is motivated by the impending oyster season (early October) and the high number of unvaccinated residents of some municipalities in Zeeland. Between 2 and 18 September samples at the sewage treatment (STP) in Rosières collected by staff from GSK and KU Leuven. Also, samples of sediment from the settler of the STP and sludge samples from the river Lasne were analyzed. Furthermore, community sewage samples were collected in some municipalities with low vaccination coverage between 30 September and 7 November. In addition, it is calculated that from 20 September the discharge could flow in the Westerschelde. Since shellfish feed by filtering water, the presence of impurities such as polio viruses, can accumulate in their gastrointestinal tract. On 24 September and 3 and 28 October, mussels collected in the eastern part of the Westerschelde, where the expected concentration polioviruses was highest, were collected and analyzed.

Just like previous years, at national level for year of report 2013, the average participation for all vaccinations included in the National Immunisation Programme (NIP) is high with 92 to 99%. Exception is the participation for HPV vaccination against cervical cancer, which increased with 2% compared to last year, to 58%. The participation for the pneumococcal vaccination (95%) and the second MMR vaccination for 9-year-olds (93%) increased also slightly compared to last year (both with 0.3%). This latter finding is important because of the aim of the World Health Organization (WHO) to eliminate measles worldwide. Furthermore, there are fewer municipalities with one or more vaccination percentages (HPV and hepatitis B excluded) below the lower limit of 90% (80 municipalities in year of report 2013 versus 90 municipalities in year of report 2012 and 107 municipalities in year of report 2011). In addition, immunisation of premature children deserves special attention. Because their immunisation is less timely, they are at increased risk of diseases against which the NIP offers protection. In 2013 experts from the Caribbean Netherlands and the RIVM will collaborate on further harmonisation of the immunisation programme on these islands with the Dutch NIP. With voluntary vaccination, a high vaccination coverage is reached in the Netherlands. High levels of immunisation are necessary in order to protect as many people individually as possible. For most target diseases in the NIP it is also important to protect the population as a whole against outbreaks. This protection is reached through group immunity.

The RIVM report 'The National Immunisation Programme in 2015' looks back on substantive and organisational developments in the Dutch National Immunisation Programme (NIP). Level of vaccination NIP As in previous years, in 2015 the national average vaccination rates for all vaccinations for infants preschoolers and schoolchildren were well above 90 percent. The vaccination rate for infants was even above 95 percent. Except for participation in the HPV vaccination programme, which, incidentally, increased from 59 to 61 percent. Participation among infants in the Dutch Caribbean to DKTP, MMR and pneumococcal vaccination was high. The islands have the same immunisation schedule as the Netherlands since this year. Glue residues A broadcast of a television programme 'Eén Vandaag' raised concern about possible presence of glue residues in syringes that were also used for vaccinations. As a precaution the use of these needles was temporarily stopped until research found health damage not to be likely through the use of needles. Maternal pertussis vaccination In 2015, the Dutch Health Council advised the Minister of Health to introduce whooping cough vaccination for pregnant women so vulnerable infants are better protected against pertussis. The RIVM Centre for Infectious Disease Control began an exploration of possible scenarios for the implementation of this maternal pertussis vaccination end 2015. Informed consent and Praeventis As of January 1, 2018, the NIP will be anchored in the newly amended Public Health Act (Wpg). For registration of vaccinations within this law explicit parental consent is required (informed consent). This authorisation may be asked during consultation with the parents. During consultation the parent (s) voluntary participation in the NIP will be discussed and the parent(s) will be asked for their permission for registration of vaccination data from their child in a national registry. The current registration system 'Praeventis' is outdated. Last year, an analysis for innovation of the system was put into motion.

This report contains the summaries of the presentations of the 18th annual workshop for the National Reference Laboratories (NRLs) for Salmonella, held in St. Malo, France on 30 May 2013. The aim of this workshop is to facilitate the exchange of information on the activities of the NRLs and the European Union Reference Laboratory for Salmonella (EURL-Salmonella). An important yearly item on the agenda is the presentation of the results of the annual ring trials organized by the EURL, which provide valuable information on the quality of the work carried out by the participating NRL laboratories. Another yearly item is the presentation of the most recent European summary report on Zoonoses by the European Food Safety Authority (EFSA). This latter report gives an overview on the number and types of zoonotic micro-organisms that were causing health problems in Europe in 2011. For several years, the number of health problems caused by Salmonella has been decreasing, but in 2011 it was still the second most significant cause, after Campylobacter, of zoonotic diseases in Europe. Other presentations give information on the molecular typing databases which are built by EFSA and by the European Centre for Disease Prevention and Control (ECDC). The database of EFSA is intended for the storage of molecular typing data of pathogens isolated from food, animal feed or animals. The one of ECDC will contain information gathered from pathogens isolated from humans. Each strain has its unique molecular typing pattern. The molecular typing data in both databases can be useful for comparing strains from different sources. This knowledge can contribute to find the source of a European or national foodborne outbreak. The workshop was organized by the EURL-Salmonella and is located at the Dutch National Institute for Public Health and the Environment. The main task of the EURL-Salmonella is to evaluate the performance of the European NRLs in detecting and typing Salmonella in different products.